Miller's Flashcards
Pinch strength after CTR returns
6 wks
Grip strenght returns after CTR when?
3 mos
difference btw AIN syndrome/pronator syndrome
AIN is motor only usually presents as Parsonage-Turner Syndrome
Pronator syndrome is due to compression
Mannerfelt lesion
FPL rupture in RA
Diagnostic finding on electrodx study for cubital tunnel syndrome
<50m/sec conduction
only time to transpose unlar n
subluxing/unstable nerve
Guyon Canal zones and assoc most common pathology
1- motor/sensory, ganglio
2- motor, hook of hamate fx
3- sensory, ulnar a thrombosis
Surgery for concomitant CTS and guyon canal syndrome
release transverse carpal ligament
Difference btw PIN and Radial tunnel syndrome
PIN is motor deficit ONLY
Radial tunnel -> a pain syndrome without motor/sensory deficits
Treatment for PIN and radial tunnel
at least 12 most nonop b4 decompression
Adson test
diminished radial artery pulse with inhalation -> consistent with subclavian vessel compression
Timing and management of pre-ganglioninc injury
not repairable
reconstruct at 3 mos
upper brachial plexus injury in obstetrics management
surgery if no biceps contraction by 6 mos
Radial nerve is out
What are the transfers to restore function
Wrist extension: Pronator teres -> ECRB (most consistent in testing)
Finger extension: FCR/FCU/FDS -> EDC
- FCR => EDC is most common
Tumb Ext: PL -> EPL
Elderly with severe long standing CTS and poor opposition
Camitz - palmaris longus transfer
Transfer for loss of adduction of thumb from ulnar n issue
ECRB to adductor pollicis
FDS-> adductor
Congenital abscence of thenar muscles
reconstruction?
Huber: ADM to thumb proximal phalanx
2-octylcyanoacrylate
dermabond
Dorsal distal phalanx flap coverage
digital island
Dorsal thumb skin coverage
FDMA kite flap
- comes from dorsal IF
Volar distal phalanx skin coverage if not doing secondary intention
Cross finger in adult
thenar flap in kids (maybe)
dorsal hand flap coverage
groin or abdomen flap
Dominante arch/artery of hand
% of people with complete arch in hand
Ulnar/superficial
80%
digital brachial index that is abnormal
< 0.7
hypothenar hammer syndreome
- when DBI > .7
- when DBI < .7
> –> sympathectomy
< – reconstruct
level wheren embolic disease occurs in the hand
PIP level
Diff btw Raynaud Disease and Phenomenon
Phenom is assoc with an undelrying disease thus treat the systemic disease
order of replant in hand
BEFNAV
bone, extensor, flexor, nerve, a/v
abx to treat infection from leech
ceftriaxone or cipro
> 50% extensor tendon injury
repair and protect mobilization
Zone 4 exten tendon injury > 50%
- how to manage
repair
place in Yoke splint (relative motion splint)
EPL rupture after nondisplaced DR fx
- how to treat
EIP transfer to EPL
Intrinsic tightness that doesn’t respond to therapy stretching
surgical release of the lateral bands
gap in tendon repair at risk for rerupture
> 3mm
minimal strands in core repair for flexor tendon repair
at least 4 core sutures
more is stronger
benefits of epitendinouse suture in flexor tendon repair
smooths surface
increase strength by 10-50%
decreases gap formation
where to flexor tendon repairs usually fail if they do
at the knots
timing of repair of flexor tendon avulsions
Type 1 -> within 1 wk b’c blood supply disrupted
Type 2,3 -> up to 6 wks
partial flexor tendon injury
< 25%-> trim
25-50% -> epi repair
>50% -> core and epitenon repair
All with protected mobilization
treatment for lumbrical plus finger
release lumbrical
pronator’s space
potential space just superficial to pronator quadratus
bug causing hand celluliti s
Group A betahemolytic strep
most common bug of necrotizing fasciitis
Group A beta-hemolytic strep
most important variable in high pressure injection finger injury
material injected
- paint is worse (oil specifically)
others: > 10 hrs on presentation, > 7k psi
pathologic tissue in medial epicondylitis
at junction of FCR/PT
aspect of SC joint that provides most stability
posterior and costoclavicular
medial to lateral footprint of rotator cuff insertion
~12mm
Beighton’s number considered to be hyperlax
> 6
impingement test vs sign
sign is no pain with impingement test after lidocaine injection
XR view for bony bankart
West point
view for hillsachs
stryker notch
internal rotation AP
ALPSA
Anterior labral periosteal sleeve avulsion
- may require an open procedure to completely address it
GLAD
Glenoid labrum articular disruption
HAGL is addressed via
subscap approach, open when open
when posterior -> scope it
indications for surgery in first time anterior shoulder dislocators
< 22 yo
contact athlete
bony bankart
open bankart with capsulorahy over scope benefits
lower recurrence
number of anchors needed in bankart repair
at least 3
number of anchors needed in bankart repair
at least 3
closing down rotator interval can be done for
MDI or inferior subluxation of HH
Best way to get into subacramial space with injection
lateral
Bear hug test
for subscap tear, good test
critical shoulder angle > 35-38 is assoc with
increase risk of rotator cuff tear
Mini open vs arthroscopic cuff repair
equivalent outcomes with less pain, better visualization and less risk
Deadmans angle
45 degrees for anchors in RCR
Barbotage procedure
guided aspiration of calcific tendinopathy
Age cut off for labral repair
< 35 should repair
> 35 tenodesis vs tenolysis
IF RED FLAG -> don’t repair, tenodes (workers comp)
Surgical treatment for labral tear in over head throwing athlete
repair
Max amount of distal clavicle that can be resected
1 cm
SC joint injury in someone around 18 where is the injury really?
physis b’c it closes so late
Treatment for latissimus avulsion
nonop: rest, PT, return to sport
Essential lesion of frozen shoulder
coracohumeral ligament and rotator interval contracture -> loss of ext rotation
Roos (East) test
Elevation of arm above head causes thoracic outlet syndrome sx’s
Failed nonop of medial scapular winging
Split pec major transfer
Fix for lateral winging
Eden Lange Transfer
- transfer levator scapulae and rhomboids
Joint where it is reasonable to scope and debride with OA
Shoulder
Elbow
Peg vs keel glenoid component difference
Peg has lower loosening
most common complication in TSA
glenoid loosening
most likely cause of humeral loosening in TSA
infection
preventing of scapular notching in rTSA
lateralize
place glenoid inferior with tilt facing down
What is Cultibacterium Acnes
Sames as proprionobacterium
Consider these tricks for trigger release in RA pt
More extensive tenosynovectomy
release pulley on radial side
consider FDS slip excision
number of people that respond to trigger finger injection
- what pt is it less effective in
60%
- diabetics
EMG findings with nerve injury
insertional activity/spontaneous activity minimal activity
neuropraxia - normal/silent/none
axonotmesis/neurotmesis - increased/fibrillations and positive sharp waves
Z plasty cuts and respective lengths gained
60 degree -> 75% increase
45 -> 50% increase
30 -> 25 % increase
Most common intra-articularsoft tissue injury of the wrist
TFCC
Most predictive of loss of reduction of DR fx treated nonop
age > 60 yo
Outcomes for Distal Radius fx op vs nonop in pts > 65 yo
Overall no difference except for . . .
Op pts with > grip strength and better xrays
Assoc injury with the below MOA:
- wrist ext + radial deviation
- wrist ext + ulnar deviation
radial -> scaphoid injury
ulnar -> TFCC
complication of hammate hook excise
ulnar n injury
15% grip strength b’c pulley for 4/5 FDP disrupted
fite bite management
gotta take to OR to washout the joint
2 most important thumb ligaments
Volar oblique -> fx frag that remains stable in bennet fx
dorsoradial -> primary restraint to dorsal dislocation od CMC of thumb
Treatment for chronic Gamekeep with arthritis
fusion
DRUJ dislocation
- dorsal
- palmar
splint
- dorsal -> supination
- palmar -> pronation
how to assess for ulnar impaction on xray
True PA xray (0 degree PA)
- any rotation causes movement of ulna
Max in Wafer procedure
4mm more will inur radioscaphocapitate (i thin kthat’s what he said)
if more needed ->< ulnar shortening
primary complication of
- DIP fusion
- DIP arhtroplasty
fusion
- K wire -> infection
- screw -> gotta listen to the lecrure wasn’t on slide
Arthroplasty -> extensor lag
best prosthetic for PIP joint replacement
constrained silicone
- good stability
inability to extent SF in FA
tendon rupture b’c ulna tends to sublux dorsal (caput ulnar syndrome)
most sensitive test for detecting early RA disease
MRI with contrast of the joint
1 compication with wrist replacement in RA
distal component loosening
When to perform complete radiocarpal arthrodesis for SLAC
when the lunate facet is arthritic
Preiser Disease
Scaphoid AVN
causes MCP joint flexion in dupuytren’s
spiral lig causes
pretendinous cord
displaces N/v structure
When to operate on duputrey
any PIPj contracture
MCP contractur e> 30
Which fascial structure is never involved in Dupuytren’s
Cleland’s
gold standard for motor nerve reconstruction
autograft
Hemangioma of skin in kid
- nautral history
70% regress by 7 yo
90% regress by age 9
Lat Epicondylitis
- main tendon involved
- other tendon involved 50% of the time
ECRB
anterior edge of EDC 50% of the time
most common cause of elbow arthritis
RA
When is ligament repair weakest?
When does repair ligament near full strength?
% of strength return compared to original tendon ?
weakest 7-10d
Nears full strength 21-28d
usually 2/3 of original strength
Sequence of functiona loss from nerve injury
- recovery sequence?
motor -> proprioception -> touch -> temp -> pain -> sympathetics
*MP Touched Toots PartS
recovery occurs reverse
