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
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
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
4
Q
Other name for the natatory and transverse lig
A
5
Q
Small skin inversions in Dupuytrens are called?
Caused by what lig?
A
6
Q
Fibers arround the A1 (often affected in Dupuytrens)
Fibers connection palmar aponeurosis to the finger
A
Legueu & Juvara
Gosset
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
8
Q
What separates FDP from lumbricals
A
Legeau & Juvara lig
9
Q
What causes this snapping of skin?
A
10
Q
Ligament dorsal to nerves and vessels in the digit?
A
11
Q
Direction of Clelands lig?
A
12
Q
Name of this fiber? (normal tissue)
A
Grayson lig
13
Q
What lig can cause this bony “exostosis”?
A
A part of affected Graysons lig
14
Q
Which 2 lig causes spiral chord
A
Gossets lig together with a part of Graysons
15
Q
Where do you find the spiral chords
A
Just distal or proximal to the natatory lig at the web crease
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
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.
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
19
Q
What causes PIP-hyperextension deformity after ulnarly deviated MCPs
A
Contracture of ulnar intrinsics
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)
21
Q
What disease
A
Scleroderma typical severe PIP flexión contracture and secondary MCP hyperextension
22
Q
Degrees for PIP fusion
A
25 dig 2,
45 dig 5
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
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.
25
What direction does wrist often deviate in RA when MCPj:s are not involved
Ulnarly
26
What comes first, wrist deviation deformity or finger in RA
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.
27
3 types of RA destruction
28
In Vaughn-Jackson what happens?
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.
29
Does Darrach increase risk of ulnar translation?
No.
Ulnar translation is due to incompetence in radiocarpal lig (short-long radio lunate and RSC)
30
Benefits of Sauve-Kampandji over Darrach?
Does not decrease risk of ulnar translation.
31
How to treat ulnar drift in MCPj in RA
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.
32
Type 1 Boutonniere of thumb
33
Type 2 Boutonniere of thumb
34
Type 3 deformity of thumb
35
Type IV of thumb deformity
36
Type V thumb deformity
37
Type VI Thumb deformity
38
Steven Hovius recommended radial nerve tendon transfer
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
39
Where attach opponensplasty?
Test by pull in attachmentpoint at MCP. If flexion at MCP is achieved move the attachmentpoint more distally
40
Opponensplasty donors
FSD 4 (loop palmar aponeurosis, FCU, FCU-loop)
EIP
Camitz
PL
Abductor digiti mini
41
High median tendon transfer
EIP -> Opponens
BR -> FPL (Free high)
ECRL -> FDP 2 (Or side to side)
42
Froments sign?
Pinch, no adductor is compensated by FPL
43
Mennerfelt sign
Unstable PIP2 in pinch with hyperflexion
dependent on instrinsic minus
(interossei not working)
44
Jeanne sign
Weak FPB leads to extension in MCP in pinch
45
EXCURSION OF
wrist tendon
finger extensors
finger flexors
46
Classic radial nerve palsy transfer
47
Pinch reconstruction after ulnar nerve injury
| May use EDC as interposition graft between APL and 1st IOM, alse graft b
48
New Zeeland split
| works almost like IP-fusion but mor supple
49
Other option for Adductor reconstruction and 1st dorsal interosseus reconstruction
50
What to consider with high ulnar nerve injury
51
Options for intrinsic reconstruction and one important test
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.
52
What is lumbrical plus finger
Retraction of FDP with the lumbrical after distal FDP injury leading to paradoxal PIP-extension when trying to flex the finger
53
Intrinsic tighthenss test
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
Most adequate surgery for instrinsic tightness involving PIP
DIR
Not correct if MCP-flexion contracture is present
55
Instrinsic tightness with rigid swan neck deformity
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
Instrinsic tightness + ulnar drift - surgery?
57
Intrinsic contracture caused by spasticity with volitional controll
58
Intrisic contracture with absent volitional control
Ulnar neurectomy (motor)
59
Where is the transverse retinacular ligament
60
Oberlin transfer and root level of innervation
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
Transverse retinacular lig function and origin
Goes from volar plate/tendon sheet around the finger
62
ORL origin insertion
From volar plate/tendon sheet
to terminal tendon insertion
aka Landsmeers ligament
63
Nerve transfer for high radial palsy
| (instead of tendon transfer McKinnon)
FCR branch ->PIN
FDS ->ECRB
64
Possible nerve transfer for opponens
| PS not so useful compared to opponensplasty
AIN - interposition nerve graft - recurrent motor branch
or
ADQ to recurrent branch by Bertelli
65
Pinch nerve transfer
By Bertelli
Opponens nerve branch - deep branch of the ulnar nerve
66
Pronation surgery
Biceps rerouting
ECRB to PT nerv transfer
67
High median nerve sec surgery
Median tendon transfers
Brachialis to AIN (long way to reeineration)
BR->FPL tendon transfer
68
Difference superficial and partial thickness and full thickness dermal thermal injury
**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
S-PIN surgery theory
Supinator comes from C5-6 while all PIN muscles from C7 and below
They are very close anatomically
70
Rules fore burn size determination
Rule of 9 (arm, leg x2, whole head)
Palm 1%
71
Quaba flap
Maryama flap
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
Becker flap
Perforant from a. ulnaris 2-4cm proximal of os pisoform, goes deep to FCU, 20cm long 9 cm wide max
73
PIA flap arteries
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
Groin flap
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
Lat dorsi flap
A. thoracodrosal fr a. subscapularis + n. thoracodorsalis. Skin 40x20cm. 10-12cm pedicle 2-3mm
| Start lateral dissekt from serratur a.
76
Vessel to fibular graft
Fibular/peronal artery/commitant veins
77
Vessel for Meidal Fermoral Condyle Graft
Descending genicular a.
or
Medial superior genicular a.
| Dual cirkulation
78
Nail grafts for germinal and sterile matrix
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
Technique for split thickness sterile matrix harvest
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
Eponychium
Perionychium
Paronychium
Hyponychium
"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
3 mimics of extensor tendon ruptur in RA
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
Mannerfelt lesion
Rupture of FPL from scaphoid osteofyte in RA
PS. Mannerfelt sign is 1st interosseous weakness after ulnar nerve palsy weak pinch dig 2
83
EDC reconstruction for RA
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
Eponychial flap
De-epitelialize marked area, primlalize the eponychiym amd suture proximally
85
How much can Moberg flap cover
2 cm
V-Y modification up to 3cm
86
Palmaris brevis innervation
Motor branch of the SUPERFICIAL nerve branch from ulnaris
87
True wrist lateral view
SPC (?)
88
Scaphoid views
4 projections
1. PA
2. oblique 45 degree pronation
3. lateral
4. Ulnar deviated PA projections 20 degree beem (probably pronation). Ziter view.
## Footnote
16% missed initially
89
Standard wrist projections
PA, lateral, oblique
90
Connection between flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger is called
Linburg-Cumstock
20%
91
Antenna procedure
92
Riche-Cannieu
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
Martin Gruber
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
Marinacci
Ulnar to median nerve anastomosis in forearm
Opposite to Martin Gruber
0,7-4%
95
Berritini
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
Prevalence of:
FDS5 abcense
Palmaris longus abcense
FDS5 6% unilateral, 6% bilateral
PL 16% uni, 9% bil (0-63%! different studies)
97
Sesamoid bones in thumb
Inside the tendons of adductor pollices and FPB
Asseccory lig attach to sesamoid
98
Adductor pollicis anatomy
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
Strickland score
(pip flexion + dip flexion)-(pip extension lag + dip extension lag)] × 100/175
100
Strickland cireteria (6)
101
Pollicization, use what to create:
EPL
APL
Abductor p brevis
Adductor p
EPL - EIP
APL - EDC2
Abductor p brevis - 1st dorsal i.o.
Adductor p - 1st palmar i.o.
102
1 and 2 Standard deviation
103
Mean
Median
Mode
| Statistics
104
Null vs Alternative hypothesis
105
Confidence intervall
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
P-value
107
Student T-test
Chi-Square test
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
Type 1 and 2 error
Menmonic
The wolf story.
1st time the boy cries is false alarm/false positive
2nd time its false negative (nobody believes)
109
Interfascicular anatomy of ulnar nerve
110
Between what muscles doea ulnar motor branch go
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
Distance from wrist
Palmar cutaneous branch of median nerve
Dorsal cutaneous branch of ulnar nerve
Superficial branch of radial nerve
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
Palmar spaces
Thenar most commonly infected
Midpalmar septum attaches to 3rd MC
Dorsally to thenar is the adductor muscle
113
Flexor retinaculum attachments
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
Risk factors for Dupuytrens disease
Men
Age
Hereditary
Alcohol overconsumption
(Low BMI)
High cholesterole
Diabetes
Not EP (as previously said)
| age adjusted total mortality rate is higher..
115
Normal scaphoid length
31mm men
27 women
screw length shorter
116
FDS origin
Humeroulnar head: medial epicondyle of humerus, ulnar collateral ligament, and coronoid process of ulna.
Radial head: superior half of anterior border of radius
117
PIP-condyle size
118
PIP- collateral lig attachment
Proper go a bit volarly, not to tubercle and the also go a little to A4 resp A3
119
PIP collateral lig when are they stretched
Proper in flexion
Ass in extension
bort most relaxed at 45 degree flexion
120
Why MCP unstable in extension, stable flexion versus PIP
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
PIP fusion union rate
95-98%
| DIP 15-20%! Non union
122
Chronic paronychia surgery
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
Leeches bacteria
Aeromonas Hydrophilia in intestinal flora
Ciprofloxacin but can give resistance - maybe other prophylaxis
124
Syphilis bacteria
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
Tularemi
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
Sporotrichosis "Rose garden disease"
Marching lymphocutaneous lesions
Special staining (periodic acid-schiff or silver)
Itraconzole or terbinafine orally
127
Most common etiology for chronic paronychia and diff diagnosis
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
Hansens disease
M. Leprae
129
Split thickness graft
130
How much gain in 60 degree Z plasty
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
