Hands & Elbow Flashcards
Flexor tendon nutrition is via?
direct vascular supply (vincula) and synovial diffusion.
The carpal tunnel contains?
median nerve and nine flexor tendons (one FPL, four FDS and four FDP). • FPL is most radial, whereas the long and ring FDS tendons are
volar to index and small FDS.
Lumbrical muscles originate where?
on the radial aspect of FDP tendons and pass volar to transverse metacarpal ligaments to insert on the radial
aspect of the extensor hood lateral bands.
decreased proximal interphalangeal (PIP) flexion with the metacarpophalangeal (MCP)
held in extension, and increased PIP flexion with MCP in flextion =
Intrinsic tightness
decreased PIP flexion with MCP in flexion and increased PIP flexion with MCP in extension? =
Extrinsic tightness
Radiographic parameters of distal radius?
Radiographic evaluation follows the 11-22-11 guide: • Radial height-11 mm; radial inclination-22 degrees; volar tilt-11
degrees
acceptable reduction parameters i distal radius fractures?
- Radial shortening less than 3 mm • Dorsal articular tilt less than 10 degrees
- Intraarticular step-off less than 2 mm
The most common complication after distal radius fracture
median nerve dysfunction
EPL tendon rupture most commonly occurs when? treatment?
as a late complication following closed treatment due to attritional wear and/or vascular insufficiency near the Lister tubercle. • Treat with EIP-to-EPL tendon transfer, because primary repair is
not possible
most common tendon injury after volar plating?
FPL
operative indications of scaphoid fracture?
Acute operative indications include more than 1 mm displacement, intrascaphoid angle greater than 35 degrees (humpback deformity), and trans-scaphoid perilunate dislocation.
• Proximal pole fracture is a relative operative indication.
Minimally displaced fractures may be treated with …….. fixation, commonly performed by percutaneous or limited open incision methods.
• Formal ORIF is recommended for …….. or those treated in a ………………..
• Guide pin placement should be …………………………………
• Volar approach potentially avoids ………………………………..of the scaphoid.
Minimally displaced fractures may be treated with headless compression screw fixation, commonly performed by percutaneous or limited open incision methods.
• Formal ORIF is recommended for displaced injuries or those treated in a delayed fashion.
• Guide pin placement should be along the central axis of both the proximal and distal fragments.
• Volar approach potentially avoids disruption of the primary dorsal
blood supply of the scaphoid.
SNAC wrist sequence?
The radioscaphoid joint is affected first, followed by the scaphocapitate and lunocapitate; the radiolunate joint is spared
the longest.
Carpal instability can be broadly classified into four types:
Carpal instability dissociative
Carpal instability nondissociative • Carpal instability adaptive
• Carpal instability complex
how does a DISI occur?
DISI is the most common form of carpal instability (increased SL angle). • Scapholunate ligament disruption • Dorsal portion strongest • Untreated chronic instability may result in scapholunate advanced collapse (SLAC) wrist with stages of involvement similar to SNAC
wrist.
describe a VISI?
VISI is the second most common (decreased SL angle) • Lunotriquetral ligament disruption • Volar portion strongest
• Natural history less clear
Perilunate dislocations are an example of carpal instability complex. • Mayfield described four stages of progressive disruption:
- I—scapholunate
- II—midcarpal
- III—lunotriquetral (perilunate dislocation)
- IV—circumferential (lunate dislocation)
describe deforming forces of a Bennett fracture?
fracture-dislocation of the thumb metacarpal base. • APL and thumb extensors cause proximal, dorsal and radial displacement of the metacarpal shaft.
• The “beak” ligament keeps the volar-ulnar base fragment
reduced to the trapezium. Adductor pollicis adduction and supination.
Thumb MCP UCL injury Instability in 30 degrees of flexion indicates ?
injury to PROPER ucl (flexion in PALM is PROPER)
what is a stenar lesion?
In over 85% of cases, a complete injury is accompanied by a Stener lesion, in which the adductor pollicis aponeurosis is interposed between the avulsed UCL and its insertion site on the
base of the proximal phalanx.
PIP dislocations most commonly occur
dorsally and result from volar plate and collateral ligament injury.
Volar PIP dislocation requires disruption of what? and treatment ? to prevent?
central slip and must be splinted in full extension following reduction to prevent a
boutonnière deformity
Rotatory PIP dislocation occurs when
one of the phalangeal condyles is buttonholed between the central slip and a lateral
band
PIP fracture-dislocations are classified based on the amount of middle phalanx (P2) articular surface involvement.
define stable fracture and treatment and unstable fracture treatment?
A volar P2 base fragment with less than 30% involvement is usually stable enough for nonoperative management, initially in a dorsal block splint.
• Unstable injuries with larger P2 base fragments often require operative intervention, such as dorsal block pinning, ORIF, hemihamate reconstruction, or volar plate arthroplasty.
• Irreducible MCP and DIP dislocations are typically due to inter
Irreducible MCP and DIP dislocations are typically due to
interposition of the volar plate; treatment is via open reduction and extraction of
the volar plate
mallet finger treatment?
Mallet finger is treated with DIP extension splinting if detected within approximately 12 weeks of injury. • A relative surgical indication is a displaced bony mallet injury
with significant volar subluxation of P3.
Dorsal injury over the PIP may disrupt? and consequence of this is?
the central slip insertion. • Lateral bands subluxate volarly. • Acute boutonnière deformity results in a posture of PIP flexion
and DIP hyperextension
If boutonniere deformity flexible ..treatment?
capener splint or
central slip reconstruction
Fundamental principles of flexor tendon repair:?
Strength of repair proportional to number of core suture strands that cross repair site
• A locking-loop configuration decreases gap formation. • Dorsally placed core sutures are stronger. • Epitendinous repair increases overall repair strength by up to
50%.
flexor tendon rehab protocols?
Klienert and duran
Early protected ROM is advocated to increase tendon excursion, decrease adhesion formation, and increase repair strength. • Active flexion protocols require a minimum four-strand core repair.
• Young children cannot comply with therapy and require cast
immobilization for 4 weeks.
Closed flexor tendon injury from forced DIP extension during grasping is termed a “jersey” finger (closed FDP avulsion in zone 1 distal to the FDS insertion).
• Profundus advancement of 1 cm or more carries a risk of ? why?
DIP joint flexion contracture or quadrigia.
• Quadrigia occurs because the middle-ring-small FDP tendons share a common muscle belly, and distal advancement of one tendon will compromise flexion of the adjacent digits, resulting in
forearm pain.
Adult trigger finger (stenosing flexor tenosynovitis) should be treated how ?
non op - injection steroid
op – A1 pulley release
Pediatric trigger thumb is more common than pediatric trigger finger. • May present with ………………deformity of the thumb interphalangeal joint and generally requires release of ………………pulley
• Pediatric trigger finger may stem from aberrant anatomy, and A1 pulley release alone may not sufficiently resolve triggering (add
………………… excision).
Pediatric trigger thumb is more common than pediatric trigger finger. • May present with fixed flexion deformity of the thumb interphalangeal joint and generally requires release of the A1 pulley
• Pediatric trigger finger may stem from aberrant anatomy, and A1 pulley release alone may not sufficiently resolve triggering (add
FDS ulnar slip excision).
what is dequervains tenosynovitis?
de Quervain tenosynovitis of the first extensor compartment often affects middle-aged women, new mothers, and golfers. • Corticosteroid injection is successful in more than 80% of patients.
• Intraoperative findings at the time of compartment release often reveal multiple slips of the APL tendon and a separate dorsal
compartment for the EPB tendon.
what is intersection syndrome?
Intersection syndrome is a tendinopathy occurring at the junction between the first and second extensor compartments.
• Commonly affects rowers and generally treated nonoperatively
Components of the triangular fibrocartilage complex (TFCC) include:
the dorsal and volar radioulnar ligaments, the articular disc, a meniscus homologue, the extensor carpi ulnaris (ECU) subsheath,
and the origins of the ulnolunate and ulnotriquetral ligaments.
Acute (class I) tears are most commonly ........................ (type IB). • No clear clinical outcome differences between open and arthroscopic repair techniques • ........................... (class II) tears are associated with positive ulnar variance and ulnocarpal impaction syndrome. • In the absence of DRUJ osteoarthrosis, the most commonly performed procedure is arthroscopic débridement and.............................
Acute (class I) tears are most commonly avulsions at the ulnar periphery (type IB). • No clear clinical outcome differences between open and arthroscopic repair techniques • Degenerative (class II) tears are associated with positive ulnar variance and ulnocarpal impaction syndrome. • In the absence of DRUJ osteoarthrosis, the most commonly performed procedure is arthroscopic débridement and ulnar shortening osteotomy.
Posttraumatic DRUJ osteoarthritis may be treated with:
hemiresection interposition arthroplasty, Darrach resection, Sauve-Kapandji
arthrodesis or prosthetic arthroplasty
Nail bed injuries with less than 50% subungual hematoma
may be treated without nail plate removal (nail trephination for pain relief).
Nail bed injuries with greater than 50% subungual hematoma may be treated
with nail plate removal and repair of underlying nail matrix lacerations.
less than 1 cm2 without exposed
bone
secondary intention
larger wound without exposed bone?
skin grafting
Volar oblique injury treated by
cross-finger or thenar flap
Transverse or dorsal oblique injury treated by
V-Y advancement (digit) or Moberg advancement flap (thumb) to preserve skeletal length; alternative treatment is skeletal shortening and closure at
level with available skin
Transverse or dorsal oblique injury treated by
V-Y advancement (digit) or Moberg advancement flap (thumb) to preserve skeletal length; alternative treatment is skeletal shortening and closure at
level with available skin
Dorsal thumb injury may require
kite flap from the index (based on first dorsal metacarpal artery).
Shortening and closing an injury that acutely violates the FDP insertion may result in
lumbrical-plus finger.
what is lumbrical plus finger?
- FDP tendon retracts and creates tension on the extensor mechanism through its intact lumbrical origin, causing paradoxical PIP joint extension with active finger flexion.
- Treat with release of the radial lateral band.
Full-thickness skin grafts are preferred for …….hand and ………..wounds, because they are more durable, contract less, and provide
better sensibility.
Full-thickness skin grafts are preferred for volar hand and fingertip wounds, because they are more durable, contract less, and provide
better sensibility.
Primary indications for replantation:
Level of amputation outside of zone II flexor tendon sheath, multiple digits, thumb, proximal amputations and any injury in a
child
Primary contraindications to replantation:
Level of amputation within zone II flexor tendon sheath, single digit amputation (except thumb), segmental, crush, prolonged
ischemia, multisystem injuries
Factor most predictive of digit survival after replantation is
mechanism of injury
Most frequent cause of early (within 12 hours) replantation failure is? treatment?
arterial thrombosis • Consider releasing constricting bandages, place extremity in dependent position, administer heparin, and perform stellate
ganglion block.
Failure after 12 hours is typically due to? treatment?
venous congestion or thrombosis. • Consider leech therapy and provide antibiotic prophylaxis against
Aeromonas hydrophila
most commonly performed secondary procedure following successful replantation.
tenolysis
test to determine completness of arches in hand?
Allen Test
the most common posttraumatic vascular occlusive condition of the upper extremity, involving the
ulnar artery in the proximal palm? treatment?
Hypothenar hammer syndrome
Treatment may include resection of the thrombosed segment and interposition vein graft or arterial conduit (better patency
rate).
Vasospastic disease with a known underlying cause is termed
Raynaud phenomenon.
Vasospastic disease without a known underlying cause is termed
Raynaud disease.
compartments in the hand?
There are 10 hand compartments: thenar, hypothenar, adductor pollicis, four dorsal interosseous, and three volar interosseous (carpal
tunnel is not a compartment).
tendons most vunerable to volkmann ischaemic contracture?
The FDP and FPL muscles are most vulnerable in Volkmann ischemic contracture.
Carpal tunnel syndrome is typically idiopathic in adults, but ………………………. is the most common association in children.
mucopolysaccharidosis
how effective is steroid injection in CTS?
Single corticosteroid injection yields transient relief in approximately 80% after 6 weeks, but only 20% are symptom
free by 1 year.
Operative techniques vary but common theme is division of ……………………; ………………..and flexor tenosynovectomy confer no additional benefit
• Endoscopic carpal tunnel release may be associated with less early scar tenderness, improved short-term function, and better patient satisfaction scores in some studies; long-term results are
largely …………. to traditional open release.
Operative techniques vary but common theme is division of transverse carpal ligament; neurolysis and flexor tenosynovectomy confer no additional benefit
• Endoscopic carpal tunnel release may be associated with less early scar tenderness, improved short-term function, and better patient satisfaction scores in some studies; long-term results are
largely equivalent to traditional open release.
what is pronator syndrome?
a compression of the median nerve in the arm/forearm. • Potential sites of compression: supracondylar process, ligament of Struthers (courses between the supracondylar process and medial epicondyle), lacertus fibrosis, between the two heads of
pronator teres muscle, FDS aponeurotic arch
how can u differentiate pronator syndrome and CTS?
May be differentiated from carpal tunnel syndrome by presence of more proximal forearm pain and paresthesias that include the distribution of the palmar cutaneous branch of the median
nerve
what is AIN syndrome
Involves motor loss of FPL, index ± long FDP, and pronator quadratus
same sites of compression as pronator syndrome.
what is cubital tunnel syndrome?
Cubital tunnel syndrome may manifest as pain, numbness, weakness. • Potential sites of compression: arcade of Struthers, medial head of triceps, medial intermuscular septum, Osborne ligament, anconeus epitrochlearis, between two heads of FCU, aponeurosis of FDS proximal edge
• Recent meta-analyses of techniques fail to show statistically significant difference in outcome between simple in situ
decompression and transposition.
what is Ulnar tunnel syndrome?
(compression in Guyon canal) is usually secondary to an extrinsic mass (e.g., ganglion, lipoma, aneurysm,
boundaries? zones? differentiate from cubital tunnel?
how to differentiate between radial nerve palsy and PIN p[alsy?
dial Nerve • Proper radial nerve palsy (“Saturday night palsy”) is differentiated from PIN compression by additional weakness of proper radial nerve–innervated muscles, such as triceps, brachioradialis, and
ECRL.
PIN compression sites?
PIN compression syndrome symptoms include distal muscle weakness. • Potential sites of compression: fascial band at the radial head, recurrent leash of Henry, proximal edge of the ECRB tendon, arcade of Frohse (proximal edge of supinator), distal edge of
supinator
what is radial tunnel syndrome?
Radial tunnel syndrome is marked by lateral proximal forearm pain rather than distal motor weakness of the hand and wrist. • Sites of compression same as PIN syndrome • Outcome of surgical decompression less predictable than for PIN
syndrome
what is Chieralgia paresthetica?
compressive neuropathy of the superficial sensory branch of the radial nerve.
seddon classification?
Seddon classification divides nerve injury into neurapraxia, axonotmesis, and neurotmesis (increasing severity).
principles of nerve repair?
Peripheral nerve repairs are best when performed early, free of tension, clean wound bed • No technique deemed superior • Gaps may be addressed with nerve conduit, decellularized nerve
allograft, or autograft
nerve transfers,
no elbow flexion?
no shoulder abduction?
Classic nerve transfers for upper brachial plexus injury • Ulnar motor branch to FCU coapted to musculocutaneous nerve (elbow flexion)
• Descending branch of spinal accessory nerve coapted to suprascapular nerve (shoulder abduction)
• Radial nerve motor branch to triceps coapted to axillary nerve
(shoulder abduction)
Basic tenets of tendon transfers:
Donor must be expendable.
• Donor must be of similar excursion and power.
• One transfer should perform one function.
• Synergistic transfers are easier to rehabilitate.
• A straight line of pull is optimal.
• One grade of motor strength will be lost after transfer.
Tendon transfers for high radial nerve palsy
• Wrist extension………………….
• Finger extension—……………..
• Thumb extension—…………..
—PT to ECRB
FCU or FCR to EDC
PL to EPL
Tendon transfer (opponensplasty) options for low median nerve palsy
FDS of ring, EIP, abductor digiti minimi, PL—all transferred to APB
Rheumatoid arthritis is a systemic autoimmune disease that often affects the synovium surrounding small joints of the hand and wrist.
• Manifestations include
rheumatoid nodules, tenosynovitis, tendon rupture, ulnar MCP drift, swan neck/ boutonnière deformities,
caput ulnae, carpal subluxation, and SLAC wrist.
Vaughan-Jackson syndrome?
describes progressive rupture of extensor tendons, starting with EDM and continuing radially, from
attrition over a prominent distal ulnar head.
Mannerfelt syndrome?
describes rupture of FPL and/or index FDP secondary to attrition over a volar STT osteophyte.
Kienböck disease (idiopathic osteonecrosis of the lunate) is most common in,,……………… and presents with …………………….dorsal wrist
pain and ……………..
Kienböck disease (idiopathic osteonecrosis of the lunate) is most common in young men and presents with nontraumatic dorsal wrist
pain and decreased grip strength.
Unexplained dorsal wrist pain in a young adult with negative ulnar variance should prompt?
mri
Lichtman classification and treatment?
Stage I
No visible changes on xray, changes seen on MRI
Rx=Immobilization and NSAIDS
Stage II
Sclerosis of lunate
Rx= Joint leveling procedure (ulnar negative patients)
Radial wedge osteotomy or STT fusion (ulnar neutral patients)
Distal radius core decompression
Revascularization procedures
Stage IIIA
Lunate collapse, no scaphoid rotation
Same as Stage II above
Stage IIIB
Lunate collapse, fixed scaphoid rotation
Proximal row carpectomy, STT fusion, or SC fusion
Stage IV
Degenerated adjacent intercarpal joints
Wrist fusion, proximal row carpectomy, or limited intercarpal fusion
what is Dupuytrens disease?
Benign fibroproliferative disorder that is sometimes inherited and sometimes sporadic
main cell type in dupuytrens?
Myofibroblasts are the predominant cell type found histologically in Dupuytren fascia, and their contractile properties are abnormal and
exaggerated.
spiral cord leads to ?
PIP contracture and NV structures pushed superficial and central.
Surgical indications include
inability to place hand flat on tabletop (Hueston test), MCP flexion contracture greater than 30 degrees, or
any PIP flexion contracture
what do you know about collagenase injections?
Emerging nonoperative treatment: collagenase injection and cord manipulation • Pooled studies show average MCP correction up to 85% and PIP correction up to 60%.
• Pain, swelling, and bruising are likely temporary adverse effects of injection.
• Skin tears are more common complications than flexor tendon
rupture.
Cordless studies have demonstrated it works
IS approved by NICE
dorsal wrist ganglion ??
scapholunate articulation
volar wrist ganglion?
—radioscaphoid or STT joint
IP ganglion?
osteophyte
distal palm ganglion?
flexor tendon sheath
Giant cell tumor of tendon sheath is the second most common soft tissue tumor and presents as a slow-growing firm mass often on the
volar aspect of a digit. treatment?
marginal excision but recurrence is high.
Other soft tissue tumors for differential diagnosis include
epidermal inclusion cyst, lipoma, schwannoma, glomus, hemangioma, pyogenic
granuloma
Must-know hand tumors: • Most common malignancy? • Most common sarcomas—?] • Most common benign bone tumor—? • Most common malignant bone tumor—? • Most common malignant primary bone tumor?
Must-know hand tumors: • Most common malignancy—squamous cell carcinoma • Most common sarcomas—epithelioid and synovial • Most common benign bone tumor—enchondroma • Most common malignant bone tumor—metastatic lung carcinoma
• Most common malignant primary bone tumor—chondrosarcoma
most common pathogen for hand infections?
s.aureus
Human bites are a potentially serious infection treated promptly with incision and drainage, especially if joint or tendon sheath is violated.
• Most frequently isolated organisms are
group A streptococci, S. aureus, Eikenella corrodens, and Bacteroides spp.
Dog bites occur more frequently than cat bites, but cat bites more commonly result in serious infections that require surgical
intervention.
Pasteurella multocida, Staphylococcus, and Streptococcus
Kanavel signs:
flexed resting posture of digit, fusiform swelling of the digit, tenderness of flexor tendon sheath, pain with passive
digit extension
name the 3 centres of limb development?
The apical ectodermal ridge controls proximal-to-distal growth.
The zone of polarizing activity formation controls radial-to-ulnar growth.
• Wingless-type controls dorsal-to-volar growth
Radial clubhand is associated with a variety of systemic problems, including. treatment?
TAR syndrome, Holt-Oram syndrome, VACTERL syndrome, and life-threatening Fanconi anemia.
Wrist centralization if elbow ROM adequate
Radioulnar synostosis is associated with
duplication of sex chromosomes
wassel classification?
1-7
distal to proximal
bifid-duplication
7 = triphalangism.
Poland syndrome
(absent pectoralis major and chest wall abnormalities) and syndactyly
apert syndrome
Apert syndrome (acrosyndactyly and mental retardation) are commonly associated with syndactyly.
Blauth classification
Type I
Minor hypoplasia
All musculoskeletal and neurovascular components of the digit are present, just small in size
No surgical treatment required
Type II
All of the osseous structures are present (may be small)
MCP joint ulnar collateral ligament instability
Thenar hypoplasia
Stabilization of MCP joint
Release of first web space
Opponensplasty
Type IIIA
Musculotendinous and osseous deficiencies
CMC joint intact
Absence of active motion at the MCP or IP joint
Type IIIB
Musculotendinous and osseous deficiencies.
Basal metacarpal aplasia with deficient CMC joint q
Absence of active motion at the MCP or IP joint.
Thumb amputation & pollicization
Type IV
Floating thumb
Attachment to the hand by the skin and digital neurovascular structures
Type V
Complete absence of the thumb
