Miller Review Hand Lectures Flashcards
Orthopaedic Hand Surgery
Epineurium
Surrounds group of fascicles
Perineurium
Extension of blood brain barrier around group of fascicles
Endoneurium
On each axon
Function of myelin
Increases conduction velocity via saltatory conduction over the nodes of Ranvier
Extrinsic nerve blood supply
Vasa nervosum
Timing of nerve repair
Immediate for clean/sharp laceration. Open wound with nerve rupture, wait 2-3 weeks for demarcation, then excise scar, then operate. If closed injury, wait 3-6 months to see if it recovers on its own.
Neurapraxia, axonotmesis, neurotmesis
Neurapraxia = stretch injury with conduction block at the axonal level, architecture still intact, recovers in 3-4 months. Axonotomesis = endoneurial level. Neurotmesis = epineurial level.
EMG findings in neurapraxia, axonotmesis and neurotmesis
Neurapraxia = no spontaneous activity, normal insertional activity. Axonotmesis/neurotmesis = increased insertional activity, fibrillations and sharp positive waves.
Timing for nerve repair/reconstruction
<18 months before motor endplate degradation
Indications for direct nerve repair
Acute laceration with no tension
Indications for conduit nerve repair
<2-3cm gap in a sensory only nerve
Indications for nerve allograft repair
3-5cm sensory only nerve
Indications for nerve autograft repair
>5cm defect or motor nerve
Principles of nerve repair
Debride back to healthy vesicles, avoid tension (<10% stretch)
Indications for grouped fascicular nerve repair
None, although you line up the original fascicles well, the risk of scar blocking conduction is too great
Best prognostic indicator for recovery after nerve injury
Better with younger age
Double Oberlin transfer
In brachial plexus injury, it could be 12 months before elbow flexion is restored, so transferring ulnar fascicles from FCU and median fascicles from FDS/FCR to motor branches of biceps and brachialis shortens the endplate reinnervation time significantly
Nerve transfer for hand intrinsic reanimation
AIN as it enters PQ is transferred to the motor branch of the ulnar nerve near the wrist
What do you see on EMG in severe carpal tunnel and motor endplate degeneration?
Positive sharp waves, fibrillations and fasciculations
Most sensitive test to determine sensory deficit in compressive neuropathy
2.83 Semes-Weinstein testing
Most sensitive physical exam test for carpal tunnel
Durkan’s > Phalen’s > Tinel’s
How far does an injured nerve grow per day
1mm/day, 1 inch/month
Nerve conduction changes in compressive neuropathy
Distal motor latency >4.5 m/sec and >3.5 m/sec for sensory latency
CTS-6
Score of 12 or greater has 80% chance of carpal tunnel syndrome, validated test used in lieu of EMG/NCS
Carpal tunnel pressure level that decreases nerve conduction
30mmHg, 0mmHg with wrist splinted in neutral
Most common variation of median nerve motor branch at carpal tunnel
50% extra-ligamentous
Most common complication in carpal tunnel release
Incomplete release
Sites of median nerve entrapment
Ligament of Struthers, 1% of population has a supracondylar process of the humerus. Lacertus fibrosis. Deep head of pronator teres. FDS arcade.
Pronator syndrome vs carpal tunnel syndrome
The palmar cutaneous branch of the median nerve will be numb in pronator syndrome, but not carpal tunnel syndrome, compression most often between heads of pronator. Tinel’s over proximal forearm, symptoms with resisted elbow flexion, resisted forearm pronation and resisted long finger PIP flexion.
Nerve syndrome associated with medial epicondylitis
Pronator syndrome
AIN syndrome
Motor only deficits in AIN and vague forearm pain. Can be compressed by PT, biceps bursa, FDS, FCR or Gantzer’s muscle (accessory FPL head)
Nerve compression syndrome associated with AIN syndrome
Parsonage-Turner syndrome
Ulnar nerve sites of compression
Arcade of Struthers, medial septum, medial head of triceps, Osborne’s ligament, FCU aponeurosis, deep flexor-pronator aponeurosis and anconeus epitrochlearis
Difference in exam in cubital tunnel vs. ulnar tunnel syndrome
Numbness in dorsal cutaneous branch of ulnar nerve seen in cubital tunnel, not in Guyon’s compression.
Wartenberg sign
Loss of adducting interosseous muscle and unopposed small finger drift due to radial nerve innervated EDM in ulnar nerve compression
Jeannes sign
MCP hyperextension w/key pinch due to adductor pollicus weakness in ulnar nerve compression
Masse sign
Loss of hypothenar musculature in ulnar nerve compression
Zones of ulnar tunnel syndrome
1) Proximal to nerve bifurcation from ganglion = sensory and motor deficits. 2) Deep motor branch from hamate fracture = motor symptoms only 3) Superficial sensory branch compressed from ulnar artery thrombosis = sensory loss only
Anatomy of the ulnar tunnel
Floor = transverse carpal ligament. Roof = volar carpal ligament. Radial = hamate. Ulnar = pisiform and ADM.
Treatment of ulnar tunnel syndrome
Can do ulnar tunnel release, release of carpal tunnel also provides relief of compression in ulnar tunnel
Sites of radial nerve compression
“FREAS” Fascial band at radial head, recurrent leash of Henry, ECRB leading edge, Arcade of Frohse at proximal supinator (most common) and distal supinator. Same sites of PIN syndrome.
Nerve compression syndrome associated with lateral epicondylitis
Radial tunnel syndrome
Wartenberg syndrome/cheiralgia paresthetica
SBRN compression
Adson test
Diminished radial artery pulse with inhalation due to sublclavian artery compression in thoracic outlet syndrome
Work-up for thoracic outlet syndrome
Non-specific paresthesias on exam that include MABC, lower plexus trunk signs with overhead activity, u/s 90% sensitive and specific, evaluate for Pancoast tumor
Branches off brachial plexus with contributions from every level
Radial and median nerve.
Pre-ganglionic lower C8-T1 root avulsion signs
Horner’s syndrome, ptosis, miosis, anhidrosis. Enapthalmos.
Treament of pre-ganglionic brachial plexus injuries
Typically reconstruction at 3 months, these do not regrow and are not amenable to repair
Treatment of post-ganglion brachial plexus injuries
If open wound and obvious injury, fix ASAP. If closed of LV GSW, observe 3-6 months, outcomes worse outcoes if later than 6 months and minimal reinnervation if you wait 1 year.
Nerve transfer options for brachial plexus root avulsions
Oberlin (FCU fascicle to musculocutaneous nerve for biceps), CN XI to SSN, branch to triceps to axillary nerve
Tendon transfer options for brachial plexus injury
Lower trap tendon transfer for external rotation
Free innervated gracilis muscle transfer
Used in late brachial plexus reconstruction
Associations with obstetric brachial plexopathy
High birth weight, large head and shoulder dystocia
Prognosis for full vs. incomplete recovery after obstetric brachial plexus palsy
Biceps/deltoid return by 2 months, expect full recovery. Biceps and deltoid return in 3-6 months, expect incomplete recovery. Surgery if no biceps function by 6 months.
Principles of tendon transfer
Adquate strength and excursion, no joint contracture, functional and expendable donors, transfer direction in line with pull, synergysm, one motor tendon unit to have one function
Tendon transfer feature that best correlates with amplitude
Fiber length, this is why you need good excursion of the tendon
At what point in muscle contraction is the force the greatest?
When muscle is at resting length
What is the concept of synergism in tendon transfers
Use a muscle that already has a similar function, for example, wrist extension and finger flexion are linked actions. Using a wrist extensor to transfer to re-establish finger flexion would be synergistic.
What factors do you want to match with tendon/muscle transfer?
Force, amplitude and direction
Tendon transfer to restore wrist extension in radial nerve injury
PT -> ECRB
Tendon transfer to restore finger extension in radial nerve injury
FCR, FCU or FDS to EDC
Tendon transfer to restore thumb extension in radial nerve injury
Palmaris, FDS or FCR to EPL
Brand tendon transfer for radial nerve injury
FCR -> EDC, PT -> ECRB, PL -> EPL
Tendon transfer for elderly patient with severe carpal tunnel syndrome and loss of opposition
Camitz: Palmaris longus to P1 of thumb to restore abduction, less so opposition
Transfer for pediatric patient with congenital absence of the thenars
Huber: ADM transfer to P1 of thumb to restore opposition
Size of fingertip injury you can heal by secondary intention
1 cm^2
Volar oblique fingertip injury with exposed bone in adult
Cross-finger flap, down side is flexion contracture
Volar oblique fingertip injury with exposed bone in child’s index or middle finger
Thenar flap, can’t do in adults because they get PIP contracture. Watch for thumb neurovascular bundle.
Volar oblique fingertip injury with exposed bone on thumb <1cm
Moberg
Benefit of digital island flap for fingertip injuries
Maintains sensory innervation, can be from same finger (homo) or different finger (hetero). May consider in index of thumb.
Treatment of transverse fingertip injury with exposed bone
V-Y, lateral V-Y (Kutler) or shortening and volar flap
Treatment for thumb fingertip injury with >1cm tissue loss and/or dorsal loss
1st dorsal MC artery kite flap
Age that can tolerate fingertip reattachment without revascularization
Up to 6 can tolerate composite graft
How does negative pressure improve wound healing
Decreased interstitial edema and bacterial load. Increased cell division and skin graft incorporation.
Benefits of full thickness skin graft
More durable, less contraction and better sensation.
How much length can you get from a z-plasty?
Depends on the angle, 50% lengthening at 45 degree angle, 75% lengthening at 60 degree angle and 25% lengthening at 30 degree angle
Percentage of hand with complete palmar arch
80% have connection between ulnar supplied deep arch and radial supplied superficial arch
Threshold for digital brachial index when evaluation for hand vascular disorders
>0.7 is normal
Baseball catcher presents with isolated numbness, cold intolerance, ischemic pain in the small and ring fingers. What studies do you want and what is the treatment?
He needs an arteriogram to evaluate for ulnar artery thrombosis and hypothenar hammer syndrome. Treatment is ligation if they have a complete arch and DBI >0.7 to limit showering of emboli. Reconstruct with reversed vein graft if DBI <0.7.
Management of small vessel occlusion in the digits in Buerger’s disease vs. other rheumatologic disorders
Buerger’s = tobacco cessation. Rheumatologic disease, calcium channel blocker and/or sympathectomy.
Digit most often affected by embolic disease
Ring finger, straight shot from the ulnar artery
Origins of embolic disease to the digits
Heart (check for murmur), sublclavian (TOS), ulnar artery aneurysms, IVDU
Raynaud’s disease
Not associated with underlying pathology, rarely progressive, often symmetric.
Raynaud’s phenomenon
Associated with underlying pathology like Sjogren’s, often one side more involved due to vaso-occlusion. Progressive.
Types of sympathectomy for Raynaud’s
Chemical (botox), thorascopic VATS and periarterial stripping of adventitia
Indications for digit replant
Thumb, multiple digits, wrist or proximal and children. Relative indication is distal to zone I.
Contraindications for digit replant
Zone II, segmental injury, prolonged ischemia, crush/avulsion, advanced age, multiple comorbidities, polytrauma
Digit ischemia time
No muscle = 12 hours warm ischemia, <24 hours cold ischemia.
Order of operations in digit replant
Bone, extensors, flexors, arteries, nerves, veins, fasciotomies
Causes of digital replant failure
1st 12 hours = arterial thrombus, After 12 hours = venous congestion, after 1 week = infection
Leeches excrete
Hirudin
Prophylaxis for leech therapy
CTX or cipro to cover aeromona hydrophilia
Most common procedure after successful digit replant
Tenolysis
Management of ring avulsion injury
Repair those with adequate circulation, repair and revascularize those with inadequate circulation with no tendon or bone injury.
Deformity associated with chronic mallet finger
Swan neck. Lateral bands migrate dorsally. After terminal extensor tendon is disrupted, more pull occurs through the central slip, extending the PIP and DIP remains flexed due to insufficient terminal tendon.
Deformity associated with chronic central slip rupture
Boutonniere. Lateral bands migrate volarly. After centeral slip is disrupted, the triangular ligament attenuates, more pull occurs through the terminal extensor tendon, extending the DIP and flexing the PIP.
Elson test
To diagnose a central slip disruption, flex the PIP and push against resistance. If DIP remains supple, no central slip injury, if DIP extends, the central slip is out and the lateral bands are activating.
Treatment for closed volar PIP dislocation with Boutonniere deformity
PIP figure 8 extension splint x 6 weeks
Non-op treatment for zone IV and V extensor tendon injury
Yoke splint
Which way do sagittal band injuries typically sublux
Ulnarly. Radial sagittal band is most commonly injured.
Physical exam diagnosis of intrinsic tightness
PIP flexion limited with MCP hyperextension, improved with MCP flexion
Physical exam diagnosis of extrinsic tightness
PIP flexion limited with MCP flexion, improved with MCP hyperextension
Pathways for flexor tendon healing
Primary) intrinsic healing from fibroblasts within the tendon. Minimal) extrinsic fibroblasts/macrophages repair from the sheath
High risk for re-rupture after flexor tendon repair
Gap >3mm after repair, minimize this with epitendinous suture
Critical pulleys to preserve to prevent bowstringing
A2 and A4, oblique in the thumb
Repair factors that increase strength of flexor tendon repair
4+ core strands, dorsal placement of suture, locking loop configuration, 3-0 or 4-0 braided suture, addition of epitendinous suture
Where do flexor tendon repairs typically fail
Knots
When is flexor tendon repair the weakest?
Days 1-10, strength increases weeks 3-6
Leddy Packer classification
FDP avulsion, 1) retracted to palm, repair early 2) retracted to A2, repair within 6 weeks 3) bone avulsion caught at A4, repair within 6 weeks 4) FDP avulsed off fracture fragment
Risk for quadrigia
FDP advancement >1cm
Management of chronic FDP avulsion
DIP arthrodesis
Rate of tenolysis after zone II flexor tendon repair
50%
Management of pediatric flexor tendon injuries
Repair and cast for 4 weeks
Indications for tenolysis after flexor tendon repair
Conservative treatment x 3-4 months, pull PROM, limited AROM
Quadrigia
Over advancement of flexor tendon causes adjacent tendons from same muscle belly to stop flexing once the tight tendon has maxed out
Lumbrical plus finger
Finger with FDP not intact, retracted proximally. When the finger flexes, the FDP tendons are attached to the lumbricals. The finger without an intact FDP insertion sees greater force through the lumbrical and that finger extends when the others flex.
Lab staining for atypical mycobacterium
Ziehl-Neelsen or Lowenstein-Jensen at 28-32 degrees for 6 weeks. Biopsy will show granuloma
Lab staining for fungus
K-OH
Lab staining for HSV
Tzank smear and viral culture
What creates the thenar and midpalmar deep spaces in the hand?
Midpalmar septum creates thenar space, hypothenar septum creates midpalmar space.
What makes up Parona’s space?
Potential space between PQ, flexor tendons, FCU and FPL. This is where the radial and ulnar bursae connect
Most common hand bug in cellulitis
Group A beta hemolytic strep
Dental hygienist with vesicles on his finger. Diagnosis and treatment?
Tzanck smear to diagnose HSV1 herpetic whitlow. Treat with observation and acyclovir. Do not I&D, that makes them worse.
Bugs that cause acute vs chronic paronychia
Acute = S. aureus. Chronic = start thinking Candida
Collar button abscess management
Volar and dorsal incisions to get to infection volar and dorsal to the intermetacarpal ligament
Most common bug in human fight bites
S. aureus, E. corrodens in 33%
Most common bug in necrotizing fasciitis
Group A beta hemolytic strep
Most important variable for outcomes in high pressure injection injuries
Material injected (organic solvents and oil-based paint worst). Other factors include time to I&D <10 hours, injection pressure <7000 psi.
Where to release A1 pulley in rheumatoid
Radial side to provide a buffer against ulnar drift, which they are already prone to
Intersection syndrome
Palpable crepitus at intersection of 1st and 2nd dorsal compartments.
Predisposition to fail non-op management of de Quervain’s
Multiple slips of APL and separate EPB compartment
Pathophysiology of lateral epicondylitis
Angiofibroblastic hyperplasia at ECRB origin
Pathophysiology of medial epicondylitis
Angiobiroblastic hyperplasia at junction of FCR and pronator teres
PLRI test
Supine with arm overhead, elbow supinated and extended. Elbow flexes with valgus force and axial load -> rotatory subluxation laterally.
Best test for PLRI
Chair push up test has better sensitivity than pivot shift sign
Most common intrinsic ligament injured in distal radius fractures
SLIL
Most common intra-articular soft tissue injury in distal radius fractures
TFCC
Treatment for EPL rupture
EIP -> EPL transfer
Primary determinant in maintaining distal radius reduction
Age > 60 = high risk of loss of reduction
AAOS guidelines for distal radius fracture operative indications
Intra-articular displacement >2mm, post-reduction shortening >3mm and residual dorsal angulation >10 degrees
Indication for dorsal plating of distal radius fractures
S-L ligament repair/reconstruction
Tendons at risk for rupture after volar plating of distal radius fractures
FPL > FDP of index finger
1 complication with ex-fix of distal radius fractures
Over-distraction and stiffness
Indications for bridge plate fixation of distal radius fractures
Highly comminuted, diaphyseal extension and polytrauma
Contraindications for bridge plate fixation of distal radius fractures
Palmar lunate facet fragment, loss of dorsal soft tissue coverage, 2nd and 3rd MC fx
Most common complication with fragment specific fixation of distal radius fractures
Symptomatic hardware
Pressure threshold in carpal tunnel to cause carpal tunnel syndrome
40mmHg
Should you perform prophylactic carpal tunnel release on asymptomatic patients with distal radius fracture?
No, there’s a high rade of persistent median neuropathy, only do it if they have persistent worsening symptoms
Next step if patient develops carpal tunnel syndrome 7-10 days after distal radius ORIF
CTR
Vitamin C dosing after distal radius fracture
500mg x 50 days, half the dose if renal disease or history of renal calculi
What are the soft tissue stabilizers on the ulnar side of the wrist?
RUPERT
When do you fix the distal ulna in distal radius fractures?
Ulnar head w/>50% displacement and 10 deg angulation
Most common complication after distal radius fracture
Median nerve dysfunction
Wrist position in scaphoid fractures vs SL ligament injury
Scaphoid = extension radial deviation
Scaphoid operative indications
>1mm displacement, proximal pole fracture, greater arc perilunate injury, fracture comminution, high demand occupation.
Most common location of scaphoid fracture in adults vs kids
Adults = waist, kids = distal pole
Operative management of nondisplaced scaphoid waist fractures
Qucker return to work and better grip strength, higher complication rate with surgery
Indication for dorsal vs volar approach for scaphoid ORIF
Dorsal = proximal pole, using 1-2 ICSRA for vascularized graft
How do you determine vascularity of the proximal pole of the scaphoid
Intra-op punctate bleeding is the gold standard
Treatment addition for scaphoid with AVN
Add vascularized bone graft
Vascularized bone graft pedicle used for scaphoid fractures on the dorsum
1-2 intercompartmental supraretinacular artery
Vascularized bone graft pedicle used for Keinboch’s disease
4th extensor compartment artery (longest pedicle)
Vascularized bone graft pedicle used on the volar side
Volar carpal branch VBG
Staging and treatment of SNAC wrist
1) Radial styloid – radial styloidectomy
How much of the distal radial styloid can you take off in a radial styloidectomy?
4mm, otherwise you violate the RSC and the carpus subluxes ulnar
Why do patients sometimes fail to recover after dorsal triquetral avulsion?
Secondary injury to DIC/DRC ligaments and/or LTIL injury
Injuries associated with hook of hamate fracture
Rupture of 4 or 5th FDP > FDS (up to 14%), ulnar nerve paresthesias from irritation in Guyon’s canal
Treatment of hook of hamate fractures? Complications of treatment?
Cast if acute, excise if chronic non-union, excision complications include ulnar nerve injury and 15% loss of grip strength because FDP looses its pulley (hook of hamate) for the 4th and 5th digits
Most common nerve injury associated with hamate body fractures
Dorsal sensory branch of the ulnar nerve
Wrist bones with retrograde blood supply
Scaphoid and capitate
Treatment of midcarpal instability non-dissociative
Non-op. If they fail then they progress to a midcarpal fusion. Can be seen in Ehler’s Danlos patient with clunking wrist.
Treatment of large radial styloid fracture with carpal instability non-dissociative
ORIF the radial styloid is usually enough, may need to repair extrinsic volar ligaments if there is still volar translation of the carpus
Most common causes of carpal instability dissociative
SLIL and LTIL injury
What is carpal instability adaptive?
Carpal instability secondary to extra-articular pathology such as distal radius malunion. Treatment for this is fixing the malunion, not reconstructing ligaments.
Example of carpal instability complex?
Combination of carpal instability dissociative (instability within carpal rows, SLIL/LTIL) and carpal instability nondissociative (instability between carpal rows, radial styloid).
Strongest part of SLIL? LTIL?
SLIL = dorsal. LTIL = volar.
Gold standard for diagnosing carpal ligament instability
Arthroscopy
Treatment for LTIL injury
Repair if acute. If chronic can perform ECU reconstruction, fusion or ulnar shortening osteotomy
Mayfield classification
Perilunate injuries
Lesser arc vs greater arc injuries
Lesser arc = ligament injuries
Treatment of perilunate injuries
Early ORIF, CTR if carpal tunnel syndrome present
Intrascaphoid angle for humpback deformity
35 degrees
SLAC stages and treatment
I) Scaphoid and radial styloid - styloidectomy
How much shortening of the metacarpal creates a 7 deg extensor lag?
2mm shortening, 5 degrees of rotation
Indication for lag screw fixation of an oblique metacarpal shaft fracture
Fracture length 2x bone diameter, need 3 screws in different planes
Biggest risk factor after ORIF of small metacarpal head fracture
AVN
Management of simple MCP joint dislocation
Gentle reduction, but don’t pull traction or you could pull the volar plate and sesamoids into the joint, making it operative
Management of complex MCP joint dislocation? Most common complication?
Typically need volar approach because sesamoid and/or volar plate are entrapped in the joint. Most common complication is digital nerve injury.
Reduction maneuver for this fracture?
Hyperextension and volar translation. Do not apply traction or you turn a simple dislocation into a complex one with the volar plate blocking the reduction
How to treat this dislocation?
Volar PIP dislocations are associated with central slip disruption. Do not do early ROM, the PIP needs to stay extended to allow it to heal and avoid boutonniere. Get DIP moving early to keep lateral bands from migrating.
Most common complication after volar PIP plate avulsion fracture?
Stiffness
Algorithm for PIP dorsal fracture dislocations
Non-op if <30% articular surface
Most important thumb ligament preventing CMC instability
Dorsoradial ligament
Thumb ligament involved in Bennet fracture deformity
Anterior ligament (volar, oblique, beak ligament)
Management of extra-articular thumb metacarpal base fractures?
Non-op if <30 degrees angulated, reduce with traction, abduction, pronation and extension
Bennett fracture deforming forces
APL, adductor and thumb extensors
Most common nerve injury when performing ORIF of Bennet fracture via Wagner approach
Dorsal sensory branch of radial nerve
Primary dynamic stabilizer of the thumb MCPJ
Adductor pollicis, inserts on proximal phalanx and ulnar sesamoid
Collateral ligament assessment for thumb UCL injury
Flexed 30 deg = proper and dorsal capsule. Extended = accessory and volar plate
Proximal phalanx displacement in skiier’s thumb
Thumb UCL injury is typically off the proximal phalanx (80%). The proximal phalanx then supinates around the radial collateral ligament
Where do RCL injuries avulse from
Metacarpal side, UCL is opposite and avulses from proximal phalanx side
Operative indications for thumb UCL injuries
>15% articular surface, 2mm displaced, Stener lesion or stage III tear with no endpoint.
In the thumb, how does the proximal phalanx rotate around an intact UCL?
It pronates
Operative indications for thumb RCL injury
Grade III injury
What is the next step?
Sesamoids are in the joint so it needs an open reduction.
In dorsal PIP dislocation, which soft tissue structures are injured? Volar?
Dorsal = volar plate and collaterals
Muscle that causes MCP instability after RCL injury
Adductor and EPL overpull
% of Stener lesions in complete UCL injury
>85%
Force seen at thumb CMC joint during pinch?
12 fold
Change in ulnocarpal contact pressure with an increase of 2mm positive ulnar variance
Transmission force increases from 20% to 40%
Treatment of type I TFCC injuries
iA) central perforation = debridement
Proximity of distal radius fracture to joint to be a Galeazzi fracture
Within 7.5cm of articular surface
Treatment of dorsal DRUJ dislocation? Volar?
Dorsal = supination
Treatment of chronic DRUJ instability after old distal radius fracture
1) Correct distal radius malunion if present. 2) ligament repair if acute injury 3) ligament reconstruction if chronic
Diagnosis?
Ulnar impaction syndrome. Note that Keinboch’s will have edema throughout the entire lunate body.
Treatment of type II TFCC injuries
These are degenerative from ulnar impaction syndrome
Surgical management of end stage DRUJ arthritis? Main complication?
Darrach = ulnar head resection. Sauve-Kapandji = DRUJ fusion and distal ulna metaphysis resection. Ulnar head arthroplasty. Main complication with all is ulnar instability.
Structures at risk with wrist arthroscopy making 1,2 portal? 6U?
1,2 = dorsal sensory branch of radial nerve, radial artery
Best x-ray to determine true ulnar variance
0-degree rotation PA x-ray with shoulder and elbow abducted and flexed to 90 degrees
Treatment of thumb CMC arthritis by stage
Stages progress as volar beak ligament fails
Treatment of PIP joint arthritis in border vs central digits?
Border = arthrodesis, central = arthroplasty (linked in RA, unlinked in OA because of collateral stability)
Highest complication with PIP arthroplasty
Implant fracture
Indications for MCP joint arthrodesis
Spasticity and high risk of dislocation after arthroplasty (CP, TBI, arthrogryposis). Typically MCP fusions are limited because hand function and ability to perform hygiene decreases as you fuse more and can’t abduct/adduct digits
Implants used and complications associated with PIP and MCP arthroplasty
Silicone = implant fracture. Pyrocarobon = loosening. CoCr on PE = poly wear.
Conditions seen in the rheumatoid hand
Bony erosions, scapholunate dissociation, volar/ulnar carpal subluxation, caput ulna syndrome (ulna sits dorsally subluxation resulting in ulnar impaction and EDM/EDC rupture), Mannerflet lesion (volar scaphoid osteophyte -> FPL, FDP FCR rupture)
What deformity happens with injury to the transverse retinacular ligament?
Swan neck deformity. The TRL keeps the lateral bands from subluxating dorsally when it is intact.
What deformity happens with injury to the triangular ligament?
Boutonniere. The triangular ligament keeps the lateral bands from subluxating palmarly when it is intact.
Tendon transfer option in the ulnar deviated rheumatoid wrist
ECRL -> ECU transfer
Management of bilateral end stage wrist rheumatoid arthritis
Fuse on wrist in flexion and the other in extension. May also consider arthrodesis in one and arthroplasty in the other (arthroplasty must have good disease control, ligament/tendon stability and minimal deformity to limit loosening)
Operative management of caput ulna in RA
Side to side tendon repairs or EIP and/or FDS tendon transfers + Darrach vs Sauve-Kapandji procedure. Don’t pick DRUJ arthroplasty due to high risk of instability.
Vaughan-Jackson syndrome
Prominent distal ulnar head in RA causes rupture of extensor tendons from ulnar to radial starting with EDM
Mannerfelt syndrome
FPL and/or index FDP rupture secondary to volar STT osteophyte abrasions in RA
Most common wrist ligament injury associated with gout
SLIL rupture is commonly associated with inflammatory arthropathy
Type of lunate associated with Keinbochs disease
In addition to articulations with the capitate and distal radius, it has an articulation with the hamate
Blood supply to lunate
Enters palmar and dorsal
Anatomic risk factors for Keinboch’s
Negative ulnar variance, decreased radial inclination and type II lunate (hamate articulation)
What determines treatment in Keinboch’s disease
Normal carpal alignment (radial shortening if negative variance, capitate shortening if normal variance, revascularize w/4th/5th extensor compartment artery) vs. carpal collapse (PRC or scaphocapitate arthrodesis, total wrist arthrodes for more severe disease)
Preiser’s disease treatment
Scaphoid AVN. 1-2 ICSRA VBG if early. If late PRC, 4 corner or total wrist
Other body parts affected in Dupuytren’s
Lederhosen’s = plantar fascia, Garrod’s knuckle, Peyronie’s
Key pathologic cell in Dupuytren’s
Myofibroblast, stimulated by prostaglandins and lysophosphatic acid and produces alpha-smooth muscle actin and pathologic production of type III collagen
Digital ligament not involved in Dupuytren’s
Cleland’s (dorsal to neurovascular bundle).
Dupuytren’s cord that causes MP contracture
Preteindinous cord, note that this does not alter the course of the neurovacular bundle
Dupuytren’s cord that causes PIP contracture
Central cord
Dupuytren’s cord that displaces the neurovascular bundle volar and central
Spiral cord
Indications for treatment in Dupuytren’s
MCP contracture > 30 and any PIP joint contracture
Collagenase is best indicated for which patients in Dupuytren’s
MP contracture. ROM improvement not as great in PIP contracture and higher risk of tendon rupture in PIP contracture (especially small finger)
Most common complication in palmar fasciectomy for Dupuytren’s?
Nerve injury (10x greater if revision case)
Most common complication with collagenase use?
Skin tear
Cord that causes DIP contracture in Dupuytren’s
Retrovascular cord
