Questions Flashcards
Where is the initial portal for wrist arthrosocpy?
typically the 3,4 portal which is 1 cm distal to lister’s tubercle
Bunnell Test: passive PIP flexion ____ when MCP are taken from flexion to extension because ____
- decreased/lost
- this tightens the intrinsics
- **the opposite would be true with extrinsic tightness
what are the transfers for EPL and EDC for PIN palsy?
-palmaris longus and FCR
Thenar flaps are best for ___ patients with ____ _____ defects on the ____ and ____ fingers
- younger
- volar oblique
- index and long
what is a kite flap and what is it good for?
1st dorsal metacarpal artery flap and for dorsal thumb defects with exposed extensor tendons
what is the warm and cold ischemia time for replanted digits?
better outcomes with < 12 hrs warm and 24 hrs cold ishcemia
name the components of the tfcc
ucl, meniscal homologue, articular disc, volar and dorsal radioulnar ligaments, and ECU tendon sheath
what is the pathology behind wartenberg’s sign?
accessory slip of extensor digiti minimi is innervated by the radial nerve that attaches to abductor digiti minimi which causes the finger to abduct
explain the difference between intrinsic plus and minus
- intrinsic plus: PIP and DIP extension and MCP flexion
- intrinsic minus: extrinsics are more powerful so you get MCP hyperextension and flexion at the PIP/DIP
intrinsic minus is aka ___ hand and seen with what conditions?
- claw hand
- not splinting in intrinsic plus, median or ulnar nerve deficiencies, volkmann contracture, crush hand, compartment syndrome
what is the quadregia effect?
overtensioning of the FDP tendons with repair can cause the adjacent flexor tendons to be overtensioned and they will not be able to get to full flexion
what is lumbrical plus?
DIP amputation, FDP disruption distal to the origin of the lumbrical, or undertensioning of the FDP graft can cause overtensioning from the sag to the lumbrical thus causing extension of PIP/DIP
***remember that lumbricals flex the MCP and extend at the DIP/PIP joints
name the 3 types of nerve injury
- neuropraxia
- axonotmesis: axon disruption
- neurotmesis: complete disruption of nerve
what is the most common position (pronation/supination and wrist flexion/extension) that leads to TFCC injury?
-forearm pronation and wrist extension; think about when athletes fall how they most commonly brace themselves; don’t overthink this
after operative treatment of a central slip injury, how are the immobilized? what joint motion is encouraged?
- PIP in full extension with DIP free
- DIP motion but flexion in particular
is there any functional outcome benefit of form PT versus patient guided PT at home s/p ORIF distal radius?
no
how might you immobilize a zone 6 extensor tendon laceration repair?
yoke splint that holds the finger repair in hyperextension but allows for MCP/PIP/DIP motion; this is helpful for motion and decreasing adhesions but doesn’t immobilize as well and risks poor patient compliance
go through the deformities with 1st CMC arthritis
CMC: adduction and flexion
MCP: hyperextension and abduction
IP: hyperflexion
what is the difference between corticosteroid injection and PT for tennis elbow/lateral epicondylitis?
- corticosteroids have worse outcomes compared to PT; remember its not traditional inflammation but rather angiofibroplasia; PRP is more reasonable
what is an important secondary stabilizer with scapholunate ligament injury that helps prevent DISI deformity with SL injury?
dorsal intercarpal ligaments
when is a wafer procedure indicated?
It is the removal of 2-4 mm of distal ulna with ulnocarpal impingement, positive ulnar variance, and continued pain from TFCC injury
Replant guidelines: fix the ___ first; ___ before ___, use ___ grafts copiously, warm ischemia has ___ time for replant vs cold
- bone
- arteries
- veins
- vein
- shorter
congenital radioulnar synostosis is caused by failure of ____ during the 7th week of gestation
segmentation
what is the optimal time for repair of transected nerve in GSW for example humeral shaft fracture?
-1-3 weeks as this allows the zone of injury to declare itself
what is the cutoff for repair of partial FDP lacerations?
60%
radial nerve palsy transfers: what is the most consistent one performed? what is used for EPL if present? what is used for EDC?
- pronator teres to ECRB
- palmaris longus
- FCR most commonly but also can use FCU or FDS
how is post axial polydactylyl inherited?
autosomal dominant
what are the steps to releases for a PIP flexion contracture?
- checkrein ligament
- accessory collaterals and volar plate
- proper collaterals
cross finger and reverse cross finger flaps: which is used for volar and which is more commonly used for dorsal?
- volar with cross finger flap and dorsal with reverse cross finger flaps
Replantation: when does arterial or venous thrombosis occur after replant? what treatment is used for venous and not arterial and what is the mechanism? what are some things you can do?
- <12 hrs is usually arterial, > 12 hours is venous
- leeches as they excrete hirudin which is 100 times more potent than heparin
- release constrictive bandages, place in dependent position, consider heparin, stellate ganglion block
what is the blood supply to the lateral arm flap?
posterior radial collateral branches off of the profunda brachii
do you resect notta’s nodule with pediatric trigger thumb?
- no
viewing from a 3/4 portal for wrist arthroscopy, what is the order of the volar extrinsic wrist ligaments?
radioscaphocapitate, long radiolunate, short radiolunate
Rupture of tendons with distal radius fractures: volar plating to distal? scaphoid nonunion/spurring? hook of hamate nonunion? screw length with volar plating?
- FPL
- radial flexor tendons
- small finger flexor tendons
- EPL
where is the incision made for SL ligament repairs? what side of the ligament is stronger, volar or dorsal? with acute repair, what do you also usually do?
- dorsally
- dorsal
- k wire fixation for 3-4 weeks
what is the cutoff for warm and cold ischemia for replantation?
- cold: 24 hrs; warm: 12 hrs
what is the problematic proximal phalanx fracture that is hard to treatment non-operatively?
- proximal metaphyseal
1st MCP skier’s thumb: text proper in ___ and accessory in ____, what is a stenar lesion?
- 30 deg flexion
- 0 deg flexion
- UCL torn off the proximal phalanx and stuck behind the adductor aponeurosis
what causes a mirror hand deformity? apical ectodermal ridge causes ___ growth while the ZPA causes ___ growth
- abnormal duplication of the zone of polarizing activity
- longitudinal
- anterior to posterior and radial to ulnar
at zone 2 for flexor tendons, where does the blood supply come from?
- synovial sheath
which is faster, digit by digit or structure by structure for replants?
- structure by structure
what approach, volar vs dorsal should be used for humpback deformity scaphoid nonunion? what is the gold standard for graft? if using a distal radius pedicle, would you go dorsal or volar?
- volar
- vascularized MFC
- dorsal because thats where the artery is
does wrist extension or flexion increase the force through the scaphoid facet and how is this easy to remember?
- flexion; just think about the mechanism of fall on outstretched wrist for SL injury
what is the triad for presentation of glomus tumor? they are benign ___
- fingertip pain, cold insensitivity, and tenderness with mass
- ** raynaud’s doesn’t have a mass***
- hamartomas
what is the worst material for high pressure injection injection injuries?
- oil > grease/chlorofluorocarbon substances > water/latex
what are the 5 sites of compression of PIN syndrome? what is the most common?
- leash of henry (radial recurrent), arcade of froshe (supinator fibrous edge), fibrous bands superficial to the radiocapitellar joint, distal edge of the supinator
- arcade of froshe
purulent flexor tenosynovitis that involves the thumb, distal forearm, and small finger spread’s through what space?
- fascial space called parona’s space in between PQ and FDP
what cells make myelin and what does myelin do to conduction velocity?
- schwann cell
- increased
what structures are injured with axonotmesis? what is left intact?
- axon and myelin are discontinuous
- usually the endo, peri, and epineurium but there are varying levels depending on the classification where the endo and peri can be affected
Peripheral Nerve Repair: Direct repair for ___ tension; conduits (bovine/porcine) are good for ___ defects with ___ nerves; allograft and autograft are good for what size defects?
- no
- < 2-3 cm
- sensory; usually digital nerves
- <5 cm for allograft and > 5 cm for autograft
what age patient does better with nerve repairs, old or young? who does better with lacerations proximal or distal?
- young
- distal
NCS: decreasing the myelination would ___ velocity and ___ latency, axonal loss would ___ amplitude
- decrease
- increase (takes more time)
- decrease
CTS: what is the threshold for monofilament test that would be positive for CTS dx? what is the most sensitive physical exam test? what is the cutoff for latency for motor and sensory? what position are night splints? status post CTR you get pinch by ___ and grip by ___ weeks
- 2.83 mm
- Durkan’s compression test
- > 4.5/3.5
- neutral as flexion or extension at the wrist increases the pressure
- 6
- 12
what is parsonage turner syndrome? what is a common nerve that is affected?
- viral illness that preceded by shoulder pain
- AIN
ulnar tunnel syndrome: what are the 3 zones of guyon’s canal?
- mixed; motor; sensory
Radial nerve/PIN: FREAS sites of compression? what is the difference with radial tunnel vs PIN? what is commonly mis-dx with radial tunnel?
- fascial band at RC joint; recurrent leash of henry; ECRB leading edge; arcade of frosche (proximal edge of supinator); distal edge of supinator
- radial tunnel doesn’t have any sensory or motor deficits
- lateral epicondylitis
what is wartenberg syndrome?
-compression of SRN under the BR and ECRL
Brachial plexus: what type of injury is Horner’s syndrome and what is the triad?
- preganglionic; ptosis, miosis, anhidrosis
Radial nerve transfers: wrist extension? finger extension? thumb extension?
- PT to ECRB
- FCR to EDC
- PL to EPL
Fingertip Injuries: > 50% ___ intolerance, volar oblique in a thumb? LF and MF with volar olique and what age? all other volar oblique?
- cold (most common complication)
- moberg
- thenar flap; just kids
- cross finger flap
Fingertip injuries: what type oblique would V-Y be good for?
- dorsal oblique
Fingertip injuries: what type oblique would V-Y be good for?
- dorsal oblique
Lumbrical plus finger: originates on ___ tendon, if lacerated and retracts then gets paradoxial ___ when they flex their fingers
- FDP
- extension
what are 2 early reasons for failure with skin grafts? Z-plasty: increasing length with 60, 45, and 30 degrees?
- shear and hematoma that prevents it from taking
- 75%, 50%, 25%
Digital brachial index: < ___ is abnormal
- 0.7
what is the cutoff DBI with hypothenar hammer syndrome between ligation vs reconstruction?
- 0.7
Replantation: warm and cold ischemia for digits? wrist and proximal?
- 12/24 (longer because there isn’t muscle like proximal to the wrist
- 6/12
Replantation failure: first 12 hrs? after 12 hrs? after 1 week? what is the most common secondary procedure?
- arterial
- venous
- infection
- tenolysis
why can you extend DIP after fowler tenotomy (release of extensor tendon over middle phalanx for swan neck deformity) but not mallet finger?
- dorsal capsule and landsmeer ligament are still intact (ORL)
intrinsic minus and plus hand
- minus: MCP hyperextension and IP flexion
- plus: MCP flexion and IP extension
epitendinous suture for flexor tendon injuries increases the strength by ___ and prevents ___ ___
- 10-50%
- gap formation
what is the space that thenar to hypothenar purulent flexor tenosynovitis can spread and give you a horseshoe abscess?
- parona’s space
felon is an infection of the ___ ___ while a paronychia is an infection of the ___ ___
- distal pulp
- nail fold
what organism with human bites?
- eikenella
what is the tendon at risk with non-op treatment of distal radius fracture? what is the transfer for treatment? what is the berst predictor for loss of reduction with CR of DR fractures? is there any evidence to support PQ repair? what is the flexor tendon that is at risk with placing the plate too distal with volar plating DR fractures?
- EPL
- EIP transfer
- Age (> 60-65)
- no
- FPL
with SL injury the lunate follows the triquetrum and goes ___, with LT injury the lunate follows the scaphoid and goes ___
- dorsal (DISI)
- volar (VISI)
- **remember the scaphoid wants to flex and the triquetrum wants to extend
what are 2 clinical complications of hook of hamate fx left untreated?
- nonunion
2. flexor tendon rupture
1st CMC joint dislocation most commonly goes ___ from disruption of ____ ligament
- dorsal
- dorsoradial
where do 80% of the ucl at the 1st MCP occur? what about for the rcl of the 1st MCP?
- distally from the PP
- proximally from the MC more common
2 mm of MC shortening results in ___ deg extensor lag, how many extensor lag with 1 mm shortening of terminal tendon with mallet finger injury?
- 7
- 25
index to small, what are the degrees of PIP fusion?
- 40, 45, 50, 55
how would you unload the lunate with keinbocks?
- shorten the radius in situations that are ulnar negative and have increased shear forces; you could also do a capitate shortening if there was no negative ulnar variance
Duputryn’s disease: what cell? what type of collagen? what ligament is not involved? bands become ___ when they become pathologic, spiral cord moves the bundle ___ and ___, that cord gives contracture at MCP joint? which cord gives contracture of the DIP joint?
- myofibroblast
- greater type III collagen
- Cleland’s ligament
- cords
- volar and midline
- pretendinous cord
- retrovascular cord
what extrinsic ligament of the wrist is the primary stabilizer after PRC?
radioscaphocapitate
what is the cell involved with dupuytren’s disease? what type of collagen becomes more prominent? what ligament is not involved?
- myofibroblast
- type III
- cleland’s ligament (cleland’s is the ceiling)
what is the order or replant?
bone - tendon - artery - veins and make sure you go structure by structure and not digit by digit
Peripheral nerve injury: what is the first lost and the last to come back? show the entire order
- motor
- motor - proprioception - light touch - sensory - temperature - sympathetic
