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FESSH exam 2022 > Other > Flashcards

Other Flashcards

1
Q

Thumb amputation classification

A

Lister
1. Good length, function, poor soft tissue
2. Subtotal - questionable length - patient requirements decide and level of amputation, maybe only soft tissue coverage
3. Total amp, preserved basal joint - lenghten
4. No basal joint - new basal joint of fused in antiposition

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2
Q

How musch can palmar advancement flap cover

A

1,5 cm without proximal releasing incision

2,5 cm with proximal releasing insicion (V-Y or Z-plasties on both sides, or transverse at prox 1/3 of P1 as island flap + skin graft)

Up to 45 degree of IP flexion

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3
Q

Nerves always go dorsal to

A

Natatory lig seldom affected. Function is to stabilize web crease.
Nerves also dorsal to Skoog transverse fibers

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4
Q

Other name for the natatory and transverse lig

A
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5
Q

Small skin inversions in Dupuytrens are called?
Caused by what lig?

A
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6
Q

Fibers arround the A1 (often affected in Dupuytrens)
Fibers connection palmar aponeurosis to the finger

A

Legueu & Juvara

Gosset

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7
Q

Volar finger cutaneous lig often affected in Dupuytrens disease?

A

Grayson lig

45 - 45 degrees but affected can be 90 degrees to finger

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8
Q

What separates FDP from lumbricals

A

Legeau & Juvara lig

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9
Q

What causes this snapping of skin?

A
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10
Q

Ligament dorsal to nerves and vessels in the digit?

A
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11
Q

Direction of Clelands lig?

A
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12
Q

Name of this fiber? (normal tissue)

A

Grayson lig

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13
Q

What lig can cause this bony “exostosis”?

A

A part of affected Graysons lig

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14
Q

Which 2 lig causes spiral chord

A

Gossets lig together with a part of Graysons

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15
Q

Where do you find the spiral chords

A

Just distal or proximal to the natatory lig at the web crease

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16
Q

Where is the digital artery most vulnerable in Dupuytrens disease

A

At the PIPj where the prox transverse arch holds the artery fixed inside the chord

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17
Q

Common finger joints affected in RA and Psoriasis arthritis

A

RA: MCP + PIP
Psoriasis: DIP

But all joints can be affected. Psoriasis give more often MCP extension contracture and less good with silicon implant. Joints more often fused than with RA.

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18
Q

Hallmark of SLE joint involvment

A

Ligamentous and volar plate laxity
Tendon sulbluxation with joint imbalance

Joint destruction less common campared to RA. OFten normal appearing joint spaces but deformity on X-ray

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19
Q

What causes PIP-hyperextension deformity after ulnarly deviated MCPs

A

Contracture of ulnar intrinsics

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20
Q

Scleroderma etiology

A

Systemic sclerosis
More common in women
disorder of small blood vessels and connctive tissue leading to fibroris incl skin (hand and face - around mouth)

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21
Q

What disease

A

Scleroderma typical severe PIP flexión contracture and secondary MCP hyperextension

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22
Q

Degrees for PIP fusion

A

25 dig 2,
45 dig 5

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23
Q

How Boutonniere in thumb developes in RA

A

Proliferative MPj synovitis bulges dorsally
->attenuation of EPB insertion, streching ext hood-> Displacement of EPL ulnarly/volarly

Check that no FPL rupture in carpal tunnel

Possible to reconstruct ext with rerouting of EPL dorsally + synovecotmi in early cases but risk of recurrence

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24
Q

Thumb swan neck cause in RA

Treatment

A

CMC1j disease, subluxation dorally/radilly or complete dislocation with adduction -> Secondary MPj hyperextension i volar plate is lax to open up grip (CMCj is fixed)

Treatmen focus on CMC1 with LRTI, If flexible MCP volar tenodesis or sesamoidesis. If fixed -> MP fusion.

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25
Q

What direction does wrist often deviate in RA when MCPj:s are not involved

A

Ulnarly

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26
Q

What comes first, wrist deviation deformity or finger in RA

A

Often MCPj first and compensatory radial deviation at wrist (Ulnarly if only wrist)). Mild wrist deviation can be spontaneously corrected efter MCPj stabilization surgery in these cases. When severe wrist deviation start at the wrist.

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27
Q

3 types of RA destruction

A
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28
Q

In Vaughn-Jackson what happens?

A

Destructive synovitis destroys ulno and radiocarpal lig. Ulna stays in place but the carpus supinates oand translates volarly (also volarly from radius due to volar inclination in radius). The radius also moves a little volarly in relation to ulna.

Ulna is actually the only bone in place in opposition to what we normally say.

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29
Q

Does Darrach increase risk of ulnar translation?

A

No.
Ulnar translation is due to incompetence in radiocarpal lig (short-long radio lunate and RSC)

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30
Q

Benefits of Sauve-Kampandji over Darrach?

A

Does not decrease risk of ulnar translation.

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31
Q

How to treat ulnar drift in MCPj in RA

A

Often 3 problems: ulnar deviation, volar subluxation and extensor tendon attenuated

Excise triangle ulnarly in extension hood incl intrinsic attachment, reconnect to next finger on the radial side. Dig 2 use EPB. Nicolle ext hood reconstruction around coll lig also corrects volar subluxation.

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32
Q

Type 1 Boutonniere of thumb

A
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33
Q

Type 2 Boutonniere of thumb

A
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34
Q

Type 3 deformity of thumb

A
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35
Q

Type IV of thumb deformity

A
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36
Q

Type V thumb deformity

A
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37
Q

Type VI Thumb deformity

A
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38
Q

Steven Hovius recommended radial nerve tendon transfer

A

Post delt + fascia lata för triceps
FCR -> ERCB (Insted PT)
FDS III -> EPL + EDC2 (Instead of FCR + PL)
FDS IV -> EDC3-5
APL tenodesis to BR

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39
Q

Where attach opponensplasty?

A

Test by pull in attachmentpoint at MCP. If flexion at MCP is achieved move the attachmentpoint more distally

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40
Q

Opponensplasty donors

A

FSD 4 (loop palmar aponeurosis, FCU, FCU-loop)
EIP
Camitz
PL
Abductor digiti mini

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41
Q

High median tendon transfer

A

EIP -> Opponens
BR -> FPL (Free high)
ECRL -> FDP 2 (Or side to side)

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42
Q

Froments sign?

A

Pinch, no adductor is compensated by FPL

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43
Q

Mennerfelt sign

A

Unstable PIP2 in pinch with hyperflexion

dependent on instrinsic minus
(interossei not working)

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44
Q

Jeanne sign

A

Weak FPB leads to extension in MCP in pinch

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45
Q

EXCURSION OF
wrist tendon
finger extensors
finger flexors

A
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46
Q

Classic radial nerve palsy transfer

A
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47
Q

Pinch reconstruction after ulnar nerve injury

A

May use EDC as interposition graft between APL and 1st IOM, alse graft b

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48
Q

New Zeeland split

A

works almost like IP-fusion but mor supple

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49
Q

Other option for Adductor reconstruction and 1st dorsal interosseus reconstruction

A
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50
Q

What to consider with high ulnar nerve injury

A
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51
Q

Options for intrinsic reconstruction and one important test

A

Bouvier test:
Flex MCP and see if PIP-extends - this meens a lasso will open up the grip. If PIP remains flexed lasso is not a good option (Zancolli around A1). Consider axtive extension of PIP with FDS och like Brand with ECRB going volar to transverse metacarpal lig.

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52
Q

What is lumbrical plus finger

A

Retraction of FDP with the lumbrical after distal FDP injury leading to paradoxal PIP-extension when trying to flex the finger

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53
Q

Intrinsic tighthenss test

A

by Richardo Finochietto from Argentina and redefiened by Bunell)

  1. Extend MCPj and measure degree of PIP-flexion
  2. Flex MCP - should increase PIP-flexion in instrinsic tightness. If force to flex PIP increases indicates extrinsic tightness
  3. Test in radial/ulnar deviation + MCPj ext

PS. Bouvier test that is done in opposite intrinsic minus hand

54
Q

Most adequate surgery for instrinsic tightness involving PIP

A

DIR

Not correct if MCP-flexion contracture is present

55
Q

Instrinsic tightness with rigid swan neck deformity

A

Both intrinsic and extrinsic thightness! Will not improve by DIR-procedure. Contracture in lateral bands, long extensor and/or joint capsule.
Add lateral band mobilization/extensor tenolysis/dorsal capsulotomy + procedure to prevent PIP-hyperextension (ex sublimis)

56
Q

Instrinsic tightness + ulnar drift - surgery?

A
57
Q

Intrinsic contracture caused by spasticity with volitional controll

A
58
Q

Intrisic contracture with absent volitional control

A

Ulnar neurectomy (motor)

59
Q

Where is the transverse retinacular ligament

A
60
Q

Oberlin transfer and root level of innervation

A

FCU fascicle to biceps branch of musculocutaneous
Modification adding to double transfer FCR from Median nerve to brachialis branch

Reliable in C5-C6 not C5-C7

61
Q

Transverse retinacular lig function and origin

A

Goes from volar plate/tendon sheet around the finger

62
Q

ORL origin insertion

A

From volar plate/tendon sheet
to terminal tendon insertion

aka Landsmeers ligament

63
Q

Nerve transfer for high radial palsy

(instead of tendon transfer McKinnon)

A

FCR branch ->PIN
FDS ->ECRB

64
Q

Possible nerve transfer for opponens

PS not so useful compared to opponensplasty

A

AIN - interposition nerve graft - recurrent motor branch
or
ADQ to recurrent branch by Bertelli

65
Q

Pinch nerve transfer

A

By Bertelli

Opponens nerve branch - deep branch of the ulnar nerve

66
Q

Pronation surgery

A

Biceps rerouting
ECRB to PT nerv transfer

67
Q

High median nerve sec surgery

A

Median tendon transfers
Brachialis to AIN (long way to reeineration)

BR->FPL tendon transfer

68
Q

Difference superficial and partial thickness and full thickness dermal thermal injury

A

**2nd degree Partial **
Both have blisters
2a. Superficial has more erythema and pain
2b. Partial less redness and pain

3rd degree Full
White, no pain, lethery, trombosed veins

2b and 3 need early tangential excision + STSG graft

69
Q

S-PIN surgery theory

A

Supinator comes from C5-6 while all PIN muscles from C7 and below

They are very close anatomically

70
Q

Rules fore burn size determination

A

Rule of 9 (arm, leg x2, whole head)
Palm 1%

71
Q

Quaba flap

Maryama flap

A

Island flap based on perforant from arteria metacarpales dorsales 1cm proximal to MCP between the MCP heads.
Venous drainage through venae comitantes - more reliable in dig 2 and 3, less dig 4. Proximal edge is the wrist. Elevated above paratenon.

Covers P1 and web space. For more distal reach/rotation extended dissektion of perforant.

Maryama - dissektion of whole a Metacarpales for more distal reach

72
Q

Becker flap

A

Perforant from a. ulnaris 2-4cm proximal of os pisoform, goes deep to FCU, 20cm long 9 cm wide max

73
Q

PIA flap arteries

A

Ulnar artery - a. interossea communis - posterior branch up between m supinator and m abductor pollucis longus - pi artery goes between EDM and ECU in intermuscular septa to middle of last 1/3 or 2cm prox of styloideus ulna/DRU - arcus carpalis dorsalis anastomosis to a. interossea anterior

Start distal find septa ECU/EDM. Go prox.avoid n interos post branch ECU

74
Q

Groin flap

A

a. circumflexa iliaca superficialis fr a. femoralis + v comittante + v epigastrica inf. 2,5cm caudal of middle lig inguinale

Go fr lat to central, include fascia fr m sartorius. Free flap start med

75
Q

Lat dorsi flap

A

A. thoracodrosal fr a. subscapularis + n. thoracodorsalis. Skin 40x20cm. 10-12cm pedicle 2-3mm

Start lateral dissekt from serratur a.

76
Q

Vessel to fibular graft

A

Fibular/peronal artery/commitant veins

77
Q

Vessel for Meidal Fermoral Condyle Graft

A

Descending genicular a.
or
Medial superior genicular a.

Dual cirkulation

78
Q

Nail grafts for germinal and sterile matrix

A

Germinal - full thickness germinal graft (2nd toe best)

Sterile - split thickness from toe are adjacent uninjured matrix

2mm primary closure

If nail avulsion use avusled natrix from nail as graft (or re-place the nail)

79
Q

Technique for split thickness sterile matrix harvest

A

No 15 scalpel
Better to thin than to thick (donor morbidity)
Visualize the blade through the graft
Bigger graft greater risk to make too thick

80
Q

Eponychium
Perionychium
Paronychium
Hyponychium

A

“On top of nail”
Proximal nail fold

Perionychium is the skin surrounding the nail

cuticle are dead cells closing the space between nail and eponychium

Paronychium are the lateral nail folds/under the nail
Hyponychium distal under the nail, thickened dermis

81
Q

3 mimics of extensor tendon ruptur in RA

A

MCP volar subluxation
Tendon ulnar subluxation
Paralysis (elbow synovitis or PIN) - tenodesis test

PIN-palsy often dig 3-4 first compared rupture ulnar first

82
Q

Mannerfelt lesion

A

Rupture of FPL from scaphoid osteofyte in RA

PS. Mannerfelt sign is 1st interosseous weakness after ulnar nerve palsy weak pinch dig 2

83
Q

EDC reconstruction for RA

A

1 tendon - suture to adjacent
2 tendons - often ulnar (dig 4 to 3, dig 5 to EIP)
3 tendons - graft PL, ECRL to best motor. Or adjacent dig 3 and dig 4-5 to FDS3
4 tendon - FDS 3 + 4 graft through interosseous membrane or graft
If fused wrist use wrist extensors
If MP destruction - arthroplasty

84
Q

Eponychial flap

A

De-epitelialize marked area, primlalize the eponychiym amd suture proximally

85
Q

How much can Moberg flap cover

A

2 cm
V-Y modification up to 3cm

86
Q

Palmaris brevis innervation

A

Motor branch of the SUPERFICIAL nerve branch from ulnaris

87
Q

True wrist lateral view

A

SPC (?)

88
Q

Scaphoid views

A

4 projections

  1. PA
  2. oblique 45 degree pronation
  3. lateral
  4. Ulnar deviated PA projections 20 degree beem (probably pronation). Ziter view.

16% missed initially

89
Q

Standard wrist projections

A

PA, lateral, oblique

90
Q

Connection between flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger is called

A

Linburg-Cumstock
20%

91
Q

Antenna procedure

A
92
Q

Riche-Cannieu

A

A communication from the ulnar to median nerve in the palm

Motor: partial or full ulnar contribution to normally median nerve innervated muscles.
55-80% (100%?)

Martin Gruber, Marinacci in forearm

93
Q

Martin Gruber

A

A connection from the median to ulnar nerve in the forearm
Often unilateral, right arm. 20-30%. Often from AIN.
Motor: hypo/thenar, 1st interosseous

=injury to median nerve at wrist can have opponens/abd funciton/ or worse with ulnar deficit if a high lesion

Marinacci unusual ulnar to median in forearm ->ulnar nerve injury at wrist can have ulnar motor function

Riche Cannieu in palm

94
Q

Marinacci

A

Ulnar to median nerve anastomosis in forearm
Opposite to Martin Gruber
0,7-4%

95
Q

Berritini

A

Most common ulnar-median anastomoses, almost like normal anatomy 60-80%!
Often sensory from 4th to 3rd common digital nerve. Can be direct to median nerve stem.

96
Q

Prevalence of:
FDS5 abcense
Palmaris longus abcense

A

FDS5 6% unilateral, 6% bilateral
PL 16% uni, 9% bil (0-63%! different studies)

97
Q

Sesamoid bones in thumb

A

Inside the tendons of adductor pollices and FPB
Asseccory lig attach to sesamoid

98
Q

Adductor pollicis anatomy

A

Oblique head (fr capitate, 2nd 3rd MC including sesamoid)
Transverse head (3rd MC)
to base of proximal phalanx
Radial artery deep palmar arcade passes through here from dorsum and ulnar nerve motor branch

99
Q

Strickland score

A

(pip flexion + dip flexion)-(pip extension lag + dip extension lag)] × 100/175

100
Q

Strickland cireteria (6)

A
101
Q

Pollicization, use what to create:
EPL
APL
Abductor p brevis
Adductor p

A

EPL - EIP
APL - EDC2
Abductor p brevis - 1st dorsal i.o.
Adductor p - 1st palmar i.o.

102
Q

1 and 2 Standard deviation

A
103
Q

Mean
Median
Mode

Statistics

A
104
Q

Null vs Alternative hypothesis

A
They are opposite and primarily you often look for evidence for or against the null hypothesis talking in favor for or against the alternative hypothesis.
105
Q

Confidence intervall

A

Confidence, in statistics, is another way to describe probability. For example, if you construct a confidence interval with a 95% confidence level, you are confident that 95 out of 100 times the estimate will fall between the upper and lower values specified by the confidence interval.

106
Q

P-value

A
107
Q

Student T-test
Chi-Square test

A

To get a P-value. The probability that the observation is caused by chance.

Comparing two groups (independent categorical variables) with
Student T-test: dependent interval variable (a number)
Chi-Square test: dependent categorical variable (a name exv a drug name)

108
Q

Type 1 and 2 error
Menmonic

A

The wolf story.
1st time the boy cries is false alarm/false positive
2nd time its false negative (nobody believes)

109
Q

Interfascicular anatomy of ulnar nerve

A
110
Q

Between what muscles doea ulnar motor branch go

A

It passes between the abductor digiti minimi and the flexor digiti minimi brevis. It then perforates the opponens digiti minimi and follows the course of the deep palmar arch beneath the flexor tendons.

111
Q

Distance from wrist
Palmar cutaneous branch of median nerve
Dorsal cutaneous branch of ulnar nerve
Superficial branch of radial nerve

A

Palmar cutaneous branch of median nerve 4-8cm (2-15)
Dorsal cutaneous branch of ulnar nerve 8cm
Superficial branch of radial nerve 9cm (radial styloid)

112
Q

Palmar spaces

A

Thenar most commonly infected
Midpalmar septum attaches to 3rd MC
Dorsally to thenar is the adductor muscle

113
Q

Flexor retinaculum attachments

A

Meidally,
To the pisiform bone
To the hook of the hamate
Laterally,
To the tubercle of the scaphoid
To the crest of the trapezium

114
Q

Risk factors for Dupuytrens disease

A

Men
Age
Hereditary
Alcohol overconsumption
(Low BMI)
High cholesterole
Diabetes
Not EP (as previously said)

age adjusted total mortality rate is higher..

115
Q

Normal scaphoid length

A

31mm men
27 women
screw length shorter

116
Q

FDS origin

A

Humeroulnar head: medial epicondyle of humerus, ulnar collateral ligament, and coronoid process of ulna.
Radial head: superior half of anterior border of radius

117
Q

PIP-condyle size

A
118
Q

PIP- collateral lig attachment

A

Proper go a bit volarly, not to tubercle and the also go a little to A4 resp A3

119
Q

PIP collateral lig when are they stretched

A

Proper in flexion
Ass in extension
bort most relaxed at 45 degree flexion

120
Q

Why MCP unstable in extension, stable flexion versus PIP

A

Trapezoid form in both joints but mor in MCP gives hypomochlion effect stretching collaterals

Collaterals dont start at rotation centre but more dorsal in MCP, a bit mor prox i PIP

121
Q

PIP fusion union rate

A

95-98%

DIP 15-20%! Non union

122
Q

Chronic paronychia surgery

A

Eponychial marsupialization
2 versions
Wedge shaped excision
Swiss roll technique 7d
Protect germinal matrix
Lift nail if involved
+ dilute providone iodine 3x/day

Cultures neg stop antibiotics 7d
Check mycobacterium, Candida, osteomyelitis, environmental factors

123
Q

Leeches bacteria

A

Aeromonas Hydrophilia in intestinal flora

Ciprofloxacin but can give resistance - maybe other prophylaxis

124
Q

Syphilis bacteria

A

Treponema pallidum - spiral bacteria

Can be congenital, primary, sec, tertiary.

Ulcer - chancre
Dactylitis, pathologic fx

PcG treatment single dose och Doxycylclin 2w
2ndary - 3w 1dose PcQ

125
Q

Tularemi

A

Francisella Tularensis - very infectious
Rodents, fly bites, inhalation

Skin ulcer, lymph swelling, fever, lymph ulcer, sepsis

Bipsy - special diagnostics staining or PCR or antibodies serological

Streptomycin

126
Q
A

Sporotrichosis “Rose garden disease”

Marching lymphocutaneous lesions

Special staining (periodic acid-schiff or silver)

Itraconzole or terbinafine orally

127
Q

Most common etiology for chronic paronychia and diff diagnosis

A

C albicans 70-97%

30% have sec colonization by Pseudomonas aeruginosa (green nail) and sec bacterial infection

Diff: Syphilis, sporotrichosis, herpetic with low, tuberculosis, blastomycosis, SCC sublingual keratoacanthoma, leukemia cutis, amyloidosis, pilonidal sinus

128
Q

Hansens disease

A

M. Leprae

129
Q

Split thickness graft

A
130
Q

How much gain in 60 degree Z plasty

A

75%
1cm length becomes 1,75

If 90 degree you ger 120% bit difficult to mobilize and 45 degree gives 50% but maybe bad cirkulation

FESSH exam 2022 (12 decks)

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