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PGY 4 > Upper Extremity > Flashcards

Upper Extremity Flashcards

1
Q

What is the difference between primary and secondary Raynauds? What’s more common?

A

Primary is most common. Secondary is due to another condition, less common but more serious.

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2
Q

What conditions are associated with raynaud’s phenomenon?

A

80-90% is related to scleroderma. Other conditions: SLE, rheumatoid arthritis, mixed connective tissue disease

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3
Q

What are symptoms of Raynauds?

A

Digital ischemia associated with cold, caffeine or emotional distress

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4
Q

What are 10 conditions related to small vessel upper extremity ischemia?

A
  • Scleroderma - SLE - Rheum arthritis - Sjogrens (dry eyes/mouth) - Buergers - Hand arm vibration syndrome - Fibromuscular dysplasia - Malignancy - Hypersensitivity angiitis - Frostbite
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5
Q

Name 8 conditions related to large vessel upper arm ischemia

A
  • Atherosclerosis - most common - left subclavian - Embolic - a fib, usually lodges in brachial - Aneurysms - Trauma - TOS - Trauma - iatrogenic access - GCA - Takayasu - Access related steal - 10-15% brachial access
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6
Q

What medical treatment options are there for Raynauds?

A

Conservative - tobacco/cold avoidance Nifidipine Losartan Bosentan (endothelium receptor blocker) for scleroderma

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7
Q

What surgical treatment options are there for upper extremity small vessel disease?

A

Thoracic sympathy to my for digital vasospasm with ulceration - symptoms return in 3-6 months Periarterial digital sympathectomy has also been described

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8
Q

What are the compartments of the forearm?

A

Volar, lateral, extensor

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9
Q

What is the most common cause of acute upper arm ischemia?

A

Emboli from cardiac source

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10
Q

Where is the 1st part of the axillary artery?

A

Superior to pec minor

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11
Q

Where is the 2nd part of the axillary artery?

A

Posterior to pec minor

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12
Q

Where is the 3rd part of the axillary artery?

A

Inferior to pec minor

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13
Q

When exposing the basilic vein or brachial artery in the bicipital groove, which nerve can lead to hyperesthesia or anestheisa of medial doral surface of the forearm?

A

Median antebrachial cutaneous nerve

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14
Q

Where does the radial artery course in the wrist (between which 2 tendons?)

A

Flexor carpi radialis and bracioradialis

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15
Q

In the antecubital fossa is the brachial artery medial or lateral to the biceps tendon?

A

Lateral. (Median nerve courses medially).

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16
Q

Between which 2 muscles does the ulnar artery course between in the forearm?

A

Flexor carpi ulnaris and flexor digitorum

17
Q

Name 7 causes of upper extremity amputation

A
  1. Trauma (80-90%) or occupational (hypothenar hammer, vibration induced, quadrilateral space, arterial TOS)
  2. Vascular disease - atheroscloersis, embolic
  3. Tumours
  4. Infection
  5. Iatrogenic (catheterization, vasopressor, vascular access)
  6. Congenital anomaly
  7. Vasospastic/small vessel: Raynaud, Buergers, Radiation induced
18
Q

What digital pressures will healing generally occur at the hand level? What about wrist level?

A

Hand - 40 mm Hg

Wrist - 60 mm Hg

19
Q

What orientation of I-I would you use to “open up” the aortic arch?

A

LAO

20
Q

What orientation of the I-I would you use to display the bifurcation of the brachiocephalic artery?

A

RAO 20 degrees

21
Q

Name 7 “high risk”/unfavourable characteristics of arch vessel disease for endovascular treatment

A
  1. Occlusion (vs stenosis)
  2. Eccentric (vs concentric)
  3. Vessel origin in ascending aorta
  4. Heavy calcification
  5. Ulceration
  6. Symptomatic
  7. Ostial lesion
22
Q

Where is the V4 segment (vertebral artery)?

A

Intracranial, intradural protion of the vertebral artery from atlanto-occipital membrane up to basilar artery

23
Q

Where is the V3 segment (vertebral artery)?

A

From top of C2 to atlanto-occipital membrane at base of skull

24
Q

Where is the V2 segment (vertebral artery)?

A

From C6 transverse process to C2

25
Q

What is the most common pathologies associated with vertebral disease in the V1, V2, V3 and V4 segments?

A

V1 - Atherosclerotic ostial lesions

V2 - extrinsic compression, traumatic/spontaneous AV fistula (due to fixation of adventitia to the periosteum)

V3 - Trauma and arterial dissection (the artery is most mobile in this section therefore vulnerable to mechanical injury)

V4 - AV fistula, aneurysmal degeneration

26
Q

Where is the V1 segment (vertebral artery)?

A

From subclavian to entrance of C6 transverse process.

27
Q

Name 10 symptoms associated with vertebrobasilar ischemia

A
  1. Disequilibrium
  2. Verigo
  3. Diplopia
  4. Cortical blindness
  5. Alternating paresthesia
  6. Tinnitus
  7. Dysphagia
  8. Dysarthria
  9. Quadriplegia
  10. Drop attacks
  11. Ataxia
  12. Perioral numbness
28
Q

What are 2 minimum anatomic requirements to justify vertebral artery reconstruction?

A
  1. Greater than 60% stenosis in BOTH vertebral arteries if both are patent
  2. Complete occlusion or >60% stenosis of dominant vertebral artery if other one is hypoplastic, occluded, or ends in posterior inferior cerebellar artery.
29
Q

What are complications associated with proximal vertebral artery reconstructions?

A
  1. Vagus/recurrent laryngeal nerve palsy 2%
  2. Horners 8-28%
  3. Lymphocele 4%
  4. Chylothorax 0.5%
  5. Stroke 1% (if combined with carotid operation, 6%)
30
Q

What is the most common operation used to reconstruct vertebral V1 disease?

A

Transposition of the proximal vertebral artery onto the adjacent carotid artery

31
Q

What are 5 causes of arch vessel aneurysms?

A

Vascular:

Infection/Inflame: syphillis, tuberculous lymphadinitis

Neoplasm:

Degenerative/drugs: most degenerative

Iatrogenic:

Congenital: thoracic outlet syndrome

Autoimmune: FMD, cystic medial necrosis, vasculitis

Trauma: trauma

Endocrine:

32
Q

What are the symptoms associated with arch vessel aneurysms?

A

Neuro - pain (chest neck abdo), brachial plexus compression, TIA, stroke

H&N - hoarseness from right recurrent laryngeal nerve compression

CV - rupture

Resp - resp insufficiency from tracheal compression, hemoptysis

Abdo

GI - dysphagia from esophageal compression

GU

Extremities: UE acute and chronic ischemia from thromboembolism

Incidental: Most often

33
Q

**What are clinical features and complications of aberrant right subclavian artery?

A
  1. Asymptomatic
  2. Kommerell’s diverticulum
  3. Non-recurrent right RLN
  4. Thoracic duct that empties into right jugulosubclavian confluence
  5. Compressive Symptoms:
  • Dysphagia Lusoria – esophagus compressed
  • Tracheal compression - cough
  1. Emboli to arm
  2. Thrombosis
  3. Rupture
34
Q

Name 6 physical signs associated with subclavian artery aneurysms

A
  1. Supraclavicular bruit
  2. Absent or diminished UE pulses
  3. Normal pulses with signs of microembolization (“blue finger”)
  4. Sensory and motor signs of brachial plexus compression
  5. Vocal cord paralysis
  6. Horners from compression of stellate ganglion cervical sympathetic chain
35
Q

How are aberrant right subclavian artery aneurysm repaired in the elective setting:

Incision/approach? 3 options

A

Incision/approach:

  1. Staged. Extraanatomic bypass (carotid subclavian) to reconstruct the aberrant subclavian artery followed by thoracotomy to oversew the origin of the Komerrell diverticulum.
  2. Side biting clamp exclusion - right or left posterolateral thorocotomy depending on position of the aortic arch, or median sternotomy.
  3. Hybrid approach: carotid subclavian bypass + TEVAR

PGY 4 (25 decks)

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