Treatment of Vascular Disorders of the Hand

Question 1

angiography is the standard study for
vascular imaging.

Answer 1

T

Question 2

The ulnar lies deep to the flexor carpi ulnaris along
its course.

Answer 2

T

Question 3

Because of the distal muscle belly of the flexor carpi
ulnaris, the underlying ulnar artery may be compressed in some
instances and may not be palpable

Answer 3

T

Question 4

The proximal and the distal position of radial artery

Answer 4

t passes through the
interval between brachioradialis and pronator teres proximally
and between brachioradialis and flexor carpi radialis distally

Question 5

The interosseous arteries and a persistent median artery are possible sources of
secondary collateral blood supply to the hand

Answer 5

T

Question 6

The superficial palmar arch located deep to the palmar
fascia and distal to the deep palmar arch

Answer 6

T

Question 7

There is significant variability
in the superficial palmar arch, which can be described as either complete or incomplete

Answer 7

T

Question 8

a complete superficial palmar arch was
found in 84.4% ofspecimens

Answer 8

T

Question 9

Variant of superficial palmer arch

Answer 9

subdivided into five variants initiated by the ulnar artery with variouscontributions from the superficial
volar branch of the radial artery, the median artery, or communicating branches from the deep palmar arch.

Question 10

dorsal branch of the radial artery after it has passed dorsally deep to the abductor pollicis longus and extensor pollicis brevis tendons and then returns volarly into the deep palm through the two heads of the first dorsal interosseous

Answer 10

T

Question 11

Before returning volarly, the dorsal
radial artery branch typically gives rise to the dorsal carpal rete
and the princeps pollicis artery.

Answer 11

T

Question 12

As the deep palmar arch crosses the
palm, it passes deep to the flexor tendons distal to the distal carpal row.

Answer 12

T

Question 13

complete deep palmar arch was found in nearly all patients
with anastomoses to one or both deep volar branches of the ulnar
artery in all patients

Answer 13

T

Question 14

the primary venous drainage of the fingers and hand
is through the dorsal veins. These vessels drain into the basilic and cephalic veins in the forearm.

Answer 14

T

Question 15

Allen test to be reliable when compared against Doppler
ultrasonography,

Answer 15

T

Question 16

nail bed
microvasculature evaluation?

Answer 16

Capillaroscopy is a technique using high-powered light microscopy to evaluate the morphology and distribution of the nail bed microvasculature
Visible spectrum evaluation may be augmented
with the use of dynamic fluorescent angiography.

Question 17

How we can differentiate between primary and secondary Raynaud phenomenon?

Answer 17

assessment of the nail bed capillaries using dynamic fluorescent angiography. the technique is a useful screening tool to
distinguish between patients with primary Raynaud phenomenon (RP) and secondary

Question 18

Duplex ultrasonography is most useful for providing real-time blood flow evaluation

Answer 18

T

Question 19

Computed tomography angiography is a
rapid and relatively noninvasive vascular imaging modality

Answer 19

T

Question 20

magnetic resonance
angiography, this may be used when it is desirable to avoid ionizing radiation

Answer 20

T

Question 21

the standard for vascular imaging is digital subtraction angiography

Answer 21

T

Question 22

Angiography also permits concomitant interventional procedures
such as intra-arterial delivery of thrombolytics or thrombectomy

Answer 22

T

Question 23

Hand ischemia commonly result following catheterization

Answer 23

F Thrombosis of the radial and ulnar
artery following catheterization may occur, but it rarely results in hand ischemia

Question 24

In critically ill patients receiving vasopressors, peripheral vasoconstriction may result in digital ischemia in up to 2% of patients

Answer 24

T

Question 25

Creation of an arteriovenous fistula for hemodialysis access may result in decreased blood flow to the hand, but only rarely does it cause ischemic why?

Answer 25

because of a steal phenomenon

Question 26

Treatment of steal phenomenon

Answer 26

distal revascularization with interval ligation (DRIL)

Question 27

Sign of chronic ischemia

Answer 27

Splinter hemorrhages in the nail beds, fingernail changes, or digital ulcers may be a sign of a more chronic etiology

Question 28

Angiography is the study of choice to characterize the level ofocclusion, sources ofcollateral flow, and possible proximal sources of emboli

Answer 28

T

Question 29

tissue plasminogen activator often is considered as an initial treatment in cases of acute ischemia

Answer 29

T

Question 30

Revascularization procedures should be reserved for cases in which there is a clear site of obstruction that either can be resected and reconstructed or bypassed to a patent distal target

Answer 30

T

Question 31

Isolated deep venous thrombosis of the upper extremity is uncommon

Answer 31

T

Question 32

What is phlegmasia cerulea dolens?

Answer 32

patients with total or near-total thrombotic occlusion of the deep and superficial veins, they may develop ischemic thrombosis,

Question 33

Classically, an episode of RP is triggered by cold exposure or emotional stress

Answer 33

T

Question 34

pallor (white) to cyanosis (blue) to reactive hyperemia (red) upon reperfusion. These episodes are associated with paresthesias and burning pain

Answer 34

T

Question 35

What are the most important diagnostic criteria for RP

Answer 35

a diagnosis requires cold sensitivity as a trigger and biphasic color changes from white to blue during an attack

Question 36

to cold sensitivity and biphasic color changes, three of the following seven criteria must be me

Answer 36

1. triggers other than cold, 2. bilateral involvement, 3. associated numbness or paresthesias, 4. well-demarcated areas ofinvolvement, 5. photographic evidence ofRP supplied by the patient, 6. involvement ofareas other than fingers or toes, and 7. presence ofthe classic triphasic color changes from white to blue to red.

Question 37

criteria for diagnosis ofprimary RP

Answer 37

normal capillaroscopy, no evidence ofsecondary causes or connective tissue disease, and negative or low antinuclear antibody titers.

Question 38

Secondary RP id painfull

Answer 38

F Unlike in primary RP which is painful but typically has a benign course, secondary RP often is associated with significant morbidity including digital ulceration and gangrene

Question 39

prevalence between M and F

Answer 39

prevalence rates range from I% in men to 30% in women across various studies

Question 40

Risk factors included

Answer 40

female gender, family history in a first-degree relative, smoking, and migraines

Question 41

mediated by sympathetic alpha-adrenergic innervation

Answer 41

T

Question 42

exacerbated by endothelial cell dysfunction, including increased endothelin-1 activity and decreased nitric oxide activity

Answer 42

T

Question 43

Treatment typically is reserved for patients with refractory primary RP or with secondary RP.

Answer 43

T

Question 44

Medical treatment

Answer 44

strong evidence supporting the use of calcium channel blockers and iloprost, limited evidence supporting the use of atorvastatin, and conflicting evidence for the use of ketanserin and bosentan phosphodiesterase-5 inhibitors including sildenafil and tadalafil demonstrated modest improvements in symptoms, duration, and frequency of attacks. Injection ofbotulinum tox

Question 45

Surgical treatment with periarterial sympathectomy may be indicated in patients who fail medical management and have persistent digital pain or ulcerations, particularly in patients with systemic sclerosis

Answer 45

T

Question 46

Surgical tech

Answer 46

(1) disrupt sympathetic tone to the palmar and digital vessels by stripping the periarterial adventitia dividing the nerve of Henle arising from the ulnar artery (2) perform distal revascularization ifthere is proximal occlusion (3) debride digital ulcers.

Question 47

Aneurysms often present as a painless, palpable, pulsatile mass that occasionally is associated with signs of local nerve compression.

Answer 47

T

Question 48

Ischemia is common with aneurysm

Answer 48

F Ischemia is uncommon unless there is associated thrombosis and embolism

Question 49

hypothenar hammer syndrome meaning

Answer 49

Traumatic thrombosis of the ulnar artery

Question 50

How much percentage of patients with RP have Hperthener ulnar syndrome

Answer 50

1.1 % and 1.6% of patients in two separate studies were found to have hypothenar hammer syndrome

Question 51

Risk factoe for Hypothenat hammer syndrom

Answer 51

men, smokers, and had occupational or hobby-related exposures to repetitive hand trauma

Question 52

Patients typically present with unilateral vascular insufficiency to the small, ring, or middle fingers; involvement of the thumb strongly suggests an alternative diagnosis

Answer 52

T

Question 53

In some patients, the small finger is spared why?

Answer 53

In some patients, the small finger is spared because of the proper ulnar digital artery to the small finger arises proximal to the Guyon canal

Question 54

Symptoms

Answer 54

pain, cold intolerance, and numbness or weakness due to local compression of the ulnar nerve

Question 55

Angiography is the standard for diagnosis of hypothenar hammer syndrome and can be used to rule out more proximal embolic sources

Answer 55

t

Question 56

The pathognomonic corkscrew sign, first described by Hammond and colleagues,42 is an early sign of chronic damage to the intima and media leading to progressive fibrosis with ectasia

Answer 56

t

Question 57

Angiography also facilitates operative planning by defining the level of involvement of the ulnar artery,

Answer 57

T

Question 58

Nonoperative treatment

Answer 58

behavioral modification, smoking cessation, and medical management with vasodilators and antiplatelet agents.

Question 59

83% of patients were treated successfully with medical management alone

Answer 59

T

Question 60

Rates of surgical intervention for patients presenting with hypothenar hammer syndrome

Answer 60

range from 17% to 71% in two separate studies

Question 61

if there is adequate distal flow with backfilling into the distal ulnar artery we can ligate the effected segment only

Answer 61

F the defect should be reconstructed with either direct repair if the defect is short enough or reconstruction with an interpositional vein or artery graft

Question 62

arterial grafts vs vein graft are more physiologic and may have improved long-term outcomes.

Answer 62

T

Question 63

Arterial graft donor sites

Answer 63

include the descending branch of the lateral femoral circumflex artery, deep inferior epigastric artery, thoracodorsal artery, or subscapular artery

Question 64

the contralateral radial artery should not be harvested because of the high incidence of occlusion or ectasia of the ulnar artery seen in the contralateral

Answer 64

T

Question 65

arterial grafts in younger and more active patient populations.is prefered

Answer 65

T

Question 66

nonoperative treatment for hypothenar hammer syndrome, 12% of patients had a complete response to treatment and 70% had a partial response to treatment;

Answer 66

T

Question 67

Buerger disease, also known as thromboangiitis obliterans, is an inflammatory disease of the small- and medium-sized arteries of the upper and lower extremities

Answer 67

T

Question 68

The common risk factors

Answer 68

Tobacco exposure is the primary risk factor

Question 69

Discontinuation of tobacco use is the only definitive treatment.

Answer 69

t

Question 70

bypass and revascularization procedures typically are not successful

Answer 70

T

Question 71

In the management of hypothenar hammer syndrome Fibrinolysis (or thrombolysis) is advocated only for treatment in cases of acute onset of digital ischemia (less than 2 weeks).

Answer 71

T

Question 72

Complications after excision occurred in 22% of slow-flow lesions and 28% of fast-flow lesions

Answer 72

T

Question 73

Glomuvenous malformations (GVMs) commonly present in the middle phalanx

Answer 73

F all GVMs were located in the distal phalanx and 59% were in the subungual region

Question 74

presenting symptoms

Answer 74

Patients typically present with a highly focal point of tenderness, which may be associated with cold intolerance and a bluish discoloration

Question 75

Clinical examination alone may be sufficient for diagnosi

Answer 75

T ultrasonography and magnetic resonance imaging may be used as adjuncts for diagnosis

Question 76

conservative treatment can work ?

Answer 76

F Surgical excision is the only known treatment, and in a retrospective review of 51 cases ofGVMs treated with excision, there was a 3.9% recurrence rate

Question 77

Pyogenic granulomas are characterized by a small (typically

Answer 77

T

Question 78

cryotherapy is better than surgical excision for pyogenic granuloma

Answer 78

F no statistical difference between the recurrence rates in these groups

Question 79

surgical excision except where a nonsurgical treatment is preferred such as in cases where the lesion is located near cosmetically sensitive or vital structures.

Answer 79

T

Question 80

the ulnar artery emerges from the Guyon canal, it is in a relatively superficial and unprotected position on the superficial aspect of the hamate where it is subject to trauma from external forces.

Answer 80

t

Question 81

Examination findings may include a pulsatile mass at the level of the wrist, subungual splinter hemorrhages, ischemic changes in the fingers, or digital ulceration

Answer 81

t

Question 82

Angiography is the standard for diagnosis of hypothenar hammer syndrome and can be used to rule out more proximal embolic sources.

Answer 82

T

Question 83

cryotherapy often required multiple treatments in the reviewed studies and because surgical excision allows single-stage treatment with the opportunity to send the lesion for pathology (Piogenic granuloma)

Answer 83

T