Introduction to Hand Surgery

Question 1

What is the Palmar Fascia?

• associated muscles
• clinical significance?

Answer 1

• Tough layer anchoring skin to skeleton
  
  • longitudinal and transverse fascia
• Extension of forearm fascia
• Tightened by palmaris longus (apes)
• Dupuytren’s disease: thickening of the fracture

Question 2

What is Dupuytren’s disease?

• causes?
• treated?

Answer 2

• Thickening of the palmar fascia
  
  • starts of as nodules then the line develops into a thickened band that stands out on the palm on the front of the arm
  • Contracture
• Causes
  
  • Genetic: more common in males
  • Smoking
  • Alcohol
  • Diabetes/epilepsy treatment
• surgical removal

Question 3

What problems can occur with the flexor tendons?

Answer 3

• traumatic rupture (cuts)
• Trigger fingers: catching of tendons at the A1 fully
• Rugby jersey finger (closed, finger hood and forcefully pulled)

Question 4

What is Trigger Fingers?

• cause?
• treatment?

Answer 4

• Catching of tendons at A1 pulley: the finger remains in a bent position
• Degenerate nodule (usually in older people)
  
  • collagen fibres get stiffer and more brittle
  • tendon kinks under load as it comes out of the sheath at that point
  • causing the collagen to break
  • thickening of sheath
• diffused swelling around the tendon
• a stiff finger that can’t be easily straightened
• due to overuse, and degeneration
• Treatment:
  
  • steroid injection,
  • cut the A1 pulley so it’s bigger so the tendon doesn’t catch as much

Question 5

What are the sensory dermatomes for the nerves in the hand?

(look at your hand and trace it, palm and dorsum)

• clinical tests for loss of sensation? (3)

Answer 5

• dryer airer compared to another
• dry rubber, different sens of friction
• two-point discrimination with paper clip

Question 6

What is carpal tunnel syndrome?

• structures it effects?
• presentation/ aetiology?

Answer 6

• Median nerve compression at wrist
• Tendons/ Nerves
• Nerve function. lost in 3 thenar muscles in severe cases
• Experience sensory symptoms in the radial half of the hand.
• occurs spontaneously in 35-45 y/o - usually in females (can get it in the 3rd trimester of pregnancy)
  
  • lots of tingling
• occurs in 75 y/o
  
  • thenar wasting - may
  • numbness
  • not as much tingling

Question 7

What are the Thenar muscles?

• innervation
• action

Answer 7

• Abductor pollicis brevis (median nerve)
• Opponens pollicis (median nerve)
• Flexor pollicis brevis (superficial=median, deep= ulnar)
• Adductor (ulnar)
• gives fine control of thumb and the ability to oppose the thumb

Question 8

What are carpal tunnel signs?

(3)

Answer 8

• Thenar wasting
• Loss of abduction
• Loss of opposition

Question 9

What is cubital tunnel syndrome?

• what causes it (3)
• what structures does it effect

Answer 9

• Ulnar nerve compression at the elbow
  
  • Medial epicondyle fascial compression
  • Arcade of Struthers: thin fibrous aponeurotic band extending from medial head of triceps to medial intermuscular septum
  • Between the ulnar and humeral heads of the flexor carpi ulnaris
• Nerve supplies the Forearm & hand muscles therefore it results in
  
  • Sensory symptoms ulnar half of hand.
  • lack of flexion in the forearm and the hand –> muscle wasting

Question 10

Which muscles are impacted in Cubital Tunnel syndrome?

• how and why?
• symptoms/ presentation

Answer 10

Hypothenar waisting - mainly seen in the medial side of the hand overall reduced grip strength, as the little finger gives the most grip strength

• Flexor digiti minimi
• Abductor digiti minimi
• Opponens digiti minimi
• struggle with gripping things, shoelaces buttons,
• experience tingling
• Interossei
• FCU, FDP (m/r/l)

Question 11

Give an overview of the Interosseous Muscles

• structure
• action
• innervation

Answer 11

• Palmar/dorsal muscles
• Insertion to proximal phalanx
• Adduction/abduction
• Insertion to extensor hood
• Interphalangeal extension
• Ulnar nerve

Question 12

What are signs of Ulnar nerve damage?

Answer 12

• Wasted hypothenar web spaces
• Paradoxical wasting thenar
  
  • the muscles underneath (the interossei) it are wasted so it looks as if the abductor pollicis and opponents pollicis are wasted
• Proximal forearm wasting
• Clawing of digits
  
  • because of intrinsic muscle wasting of the flexor

Question 13

What are the extensor tendons?

Answer 13

• Extend MCP joints of fingers
• Thumb tendons
• Wrist tendons
• Extensor Retinaculum
• 12 in all
• Some multistranded (APL/EDC/EDQ)

Question 14

What is Quervain’s disease?

• causes

Answer 14

• caused by Thickening of the extensor retinaculum
  
  • can also be caused by degeneration
  • similar to trigger fingers
• Triggering and pain of thumb extensors as the tendons kink as they pass through that point
• Due to
  
  • overuse (hammer)
  • Ciprofloxacin (antibiotic)
  • Anastrazole (hormonal manipulation for breast cancer)

Question 15

Label this diagram?

-

Answer 15

Question 16

What are ruptures that can occur in the dorsal extensor?

Answer 16

• Lacerations
• Fracture
• Synovitis
• Arthritis
• No triggering

Question 17

Give an overview of the Digital extensor hood

• clinical significance

Answer 17

• Long extensors
• Interossei
• Lumbrical
• Finely balanced
• Complex multibundle flat tendon
• Mallet finger in the elderly: rupture of the tendon after minor activity –> dropped tip of the fingers

Question 18

Give an overview of the Osteology of the hand

Answer 18

• 3 phalanges in fingers
• 2 phalanges in thumb
• 5 metacarpals
• 2 sesamoids in thumb
• 8 carpal bones

Question 19

What are the carpal bones?

Answer 19

Question 20

What are bone problems of the hand?

Answer 20

• Radial fracture - most common wrist injury
• Scaphoid fracture - second most common
  
  • falling on an outstretched hand
• 1st CMC osteoarthritis
• Rheumatoid arthritis

Question 21

What is this an image of?

Answer 21

• Thumb base osteoarthritis
  
  • lots of joint spaces
• the majority aren’t painful

Question 22

What pathology does this X-ray show?

Answer 22

Rheumatoid arthritis