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vascular disorders hand > Vascular occulsion > Flashcards

Vascular occulsion Flashcards

1
Q

What is hypothenar hammer syndrome?

What is the incidence adn risk factors?

A

Post traumatic digital ischaemia by thrombosis of

ulna artery in Guyon’s canal

Males 9:1 Females

40-60 yrs

usually dominant hand- ring or little finger, thumb spared

risks: vibration tools, sports- baseball catchers/ golfers

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2
Q

What is the pathology of hypothenar hammer syndrome?

A

single or repetitive blunt impact to hypothenar eminence -> ulna artery thrombosis or aneursym

Hook of Hamster acts as an anvil for thrombosis

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3
Q

Describe the course of the ulna artery as it exits Guyon’s canal?

A

It branches into 2 - Superifical and Deep branch

its relationship to the hook of hamate- over distal 2cm, the artery is directly anterior to the hook of the hamate, covered by palmaris brevis, subcutaneous tissue and skin

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4
Q

what are the symptoms and signs of hypothenar hammer syndrome?

What test could you do confirm diagnosis?

A

Symptoms-

pain over hypothenar eminence and ring finger

cold senstivity

parasthesia

Signs:

blanching, mottlying, ulceration

tenderness over hypothenar eminence

prominent callus

pulsatile mass if aneurysm present

Allen’s test- positive if occulsion

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5
Q

What imaging is useful for diagnosis?

What is ths Differential diagnosis for this condition?

A

Doppler- first line

Angiogram Ct/MRI to confirm occulsion around hook of hamate

Raynaud’s disease- where the thumb is involved not so in hypothenar Hammer syndrome

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6
Q

What is the treatment for Hypothenar hammer syndrome?

A

Non operative:

lifestyle changes- smoking cessation, avoid recurrent trauma= 80% success

Operative= when ischaemis in multiple digits= >

Resection of thrombotic / aneurysmal segment +/- local sympathectomy

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7
Q

Raynaud’s syndrome consists of 2 diseases, name them?

A

Raynaud’s Disease

Raynaud’s phenomenon

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8
Q

What is the difference between Raynaud’s disease and phenomenon?

A

Phenomenon= vasospastic disease with a cause/ disease

Disease= vasospastic disease with no cause found

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9
Q

Can you describe the Epidemiology of raynaud’s phenomena?

Describe its pathology and signs?

A

Women >40

Female predominence

Path: Periodic digital ischemia induced by cold temperature or sympathetic stimuli including pain or emotional stress

Signs- triphasic colour change- white- blue -red

white= due to vasospam

blue to venous statsis

red- rebound hyperaemia

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10
Q

What are the condiiton assocaited with Raynaud’s phenenoma?

A

Connective tissue disorders-

Scleroderma (80-90%)

SLE (18%-26%)

Dermatomyositis (30%)

RA (10%)

CREST Syndrome= calcinosis, Raynaud’s, Eosphaygeal dysmolitiy, scleroderma, telangectasia

Neurovascular Compression- thoracic oulet syndrome

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11
Q

Are studies helpful in raynaud’s phenomenon?

What is the TX?

A

Yes often abnormal blood chemistry, microangiology, angiography

Tx Non operative : treat underyling disease

Lifestyle modifications

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12
Q

Are studies helpful in Raynaud’s disease?

How is it tx?

A

No- normal biochem etc, normal allen’s test, as no underlying diseae is causeative

Tx; Non operative

lifestyle changes, avoid cold temperature, cessation smoking

medication- ca channel blockers, dipyridamole (Persantine),

Surgery- Sympathectomy if consx tx fail

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13
Q

What is Buerger’s disease aka Thromboangitis obliterans?

A

A nonartherosclerotic, segmental inflammatory disease of small and medium vessels of hands and feet

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14
Q

What is the epidemiology of Buerger’s disease?

What are the risk factors?

A

Common in smokers

Typically effects patients <45 yrs

Males 3: 1 female

Smoking and chewin tobacco

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15
Q

What is the pathology of Buerger’s disease?

A

Inflammation and clotting of the small vessels of hand and feet

3 Phases

Acute- thrombus including neutrophils occlud vessel lumen sparing wall.

Subacute- organisaiton of the thrombus

Chronic- inflammation subsides- organised thrombus and fibrosis remains

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16
Q

What is the prognosis of Buerger’s disease?

A
  • *94%** who quit smoking avoid amputation
  • *43% chance of amputation within 8 years** if smoking is continued
17
Q

What are the signs and symptoms of Buerger’s disease?

A

Intermittent claudication of feet and hands

Numbness/ tingling in extremities

rest pain

Signs- ulceration,large erythermatous blood vessels, necrosis of digit tips

sensory findings 70% patients

Absent pulses

Positive allen’s test

18
Q

What investigations are useful for Buerger’s disease?

A

Arteriography- see corkscrew vessels (pic)

19
Q

What is the tx for Buerger’s disease?

A

Non operative-

Smoking cessation

Symptomatic treatment- avoid cold, daily aspirin,gentle exercise

Smoking cessation is the only treatment known to reduce the chances of amputation

Surgical

Sympathectomy- controversial- cut nerves in pain area

Amputation- if gangrene/non healing ulces/ refractory pain

20
Q

What is this?

What is it characterised by?

A

Frostbite

Extensive soft tissue damage associated with exposure to temperatures below freezing point

21
Q

What is the pathology of frostbite?

A

Cellular- movement of water from intracellular to extracellular which leads to cell dehyration and cell death

Ice crystals form extracellularly when temp = 6-15 degrees Celsius

Sensory nerve defecit ouccurs around 10 degrees celsius

22
Q

What is the prognosis of frostbite?

A

Worsened with alcohol/ intoxication

contact skin with ice/ metal

elevated wind chill factor

23
Q

How does a patient present with frostbite?

Are any investigations helpful?

A

Development of blisters 6-24 hr post warming

superifical lesions= clear

Haemorrhagic- deeper= normal painless

Bone scan at 3rd day post injury can give idea on severity

24
Q

How would you tx a patient with Frostbite?

A

Initial resuscitation with warm IV fluids

Rewarming of the affected extremity

Wound care and topical antibiotics (prevent superficial infections)

Rewarming of body part

Perform in waterbath at a temperature of 40-44 degrees Celsius for 30 minutes.

This may require IV analgesia or even conscious sedation. Repetitive freeze-thaw cycles should be avoided

wound care

Topical aloe vera, extremity elevation and splinting white/clear blisters- require debridement

hemorrhagic blisters- should be drained, but left intact

IV tissue plasminogen activator if no evidence of blood flow.

25
Q

When would surgery be required in frostbite?

A

1) Circumferential frostbite-> Immediate surgical escharotomy
2) Surgical debridement +/- amputation - once demarcating is complete - may take 1-3 months

26
Q

What are the complications of frostbite in adults?

In children?

A

Adults

Cold intolerance

Vasopasic disease- Ca channel blockers or surgical sympathetectomy

Children

Premature Growth plate closure

Joint laxity, short digits, degenerative disease- seen in patients >10 yrs with earlier disease.

27
Q

What is Complex Regional pain syndrome aka Reflex Sympathetic Dystrophy?

When is this condition caused causalgia?

A

Sustained sympathetic activity in perpetuated reflex arc characterised by pain out of proportion to phsical examination findings

When a defined nerve is involved

28
Q

What is the pathophysiology?

A

Trauma from an exageratted response to trauma- common poor outcome post crush injury ( foot)

Surgery

Prolonged Immobilisation

Possible malingering (vorgetäuscht)

29
Q

How can CRPS be prevented?

A

Vitamin C 500 mg daily is an effective prophylactic agent in distal radius fractures treated with conservative management-

Vitamin C also has been shown to decrease the incidence of CRPS (type I) following foot and ankle surgery

Avoid tight dressings and immobilisation

Vitamin C is thought to

  • reduce lipid peroxidation
  • scavenge free hydroxyl radicals
  • protect the capillary endothelium
  • inhibit vascular permeability.

RCT by Zollinger in Lancet 1999- 115 adults with 119 fractures treated with conservative management. They found that RSD/CRPS occurred in four (7%) wrists in the vitamin C group (500mg daily for 50 days) and 14 (22%) in the placebo group.

2nd study by Zollinger in JBJS Br317 adult patients sustaining 328 distal radius fractures treated conservatively. They had allocated treatment groups to 200mg, 500mg, or 1500mg vitamin C dosages for 50 days. RSD/CRPS occurrence was 4.2% in the 200mg group, 1.8% in the 500mg group, and 1.7% in the 1500mg group and thus the 500mg dosage for 50 days was recommended at the conclusion of the study.

surgically - Cazanueve et al belgium Acta orthop 2002- evaluated 195 patients who underwent open reduction internal fixation of a distal radius fracture. The first 100 did not receive vitamin C postoperatively. The next 95 patients received oral vitamin C for 45 days beginning the first day after surgery. The patients who received vitamin C had 5 times less incidence (2% vs. 10%) of reflex sympathetic dystrophy.

30
Q

What is the classification system for CRPS?

A

Lankford and Evans ( bonnie lankford had red hair- red hands)

1) Acute 0-3 months, Pain, swelling, warmth, redness, decreased ROM, hyperhidrosis - picture- Normal xrays but positive 3 phase bone scan

2) Sub- Acute, 3-12mo, Worse pain, cyanosis, dry skin, stiffness, skin atrophy. xray= Osteopenia

3) Chronic >12 mo, Dimished pain, fibrosis, glossy skin, joint contractures. xray- Extreme osteopenia

31
Q

What is the international study for pain classification of CRPS?

A

Type 1- CRPS without demonstrated nerve lesion=Most common

Type 2= CRPS with nerve damage

32
Q

What are the cardinal signs of CRPS?

A

exacerbated Pain

Swelling

Stiffness

Skin discolouration

33
Q

What do you find on clinical examination of CRPS?

A

Trophic skin changes

Hyperhydrosis

vasomotor disturbance

Flamingo gait if knee involved

34
Q

What investigations are useful in CRPS?

A

Xrays- define level of ostepenia

3 Phase bone scan-

Phase 1 ( 2 mins)= arteriogram

Phase 2 (5-10mins) cellulitis/synovial inflammation

phase 3 ( 2-3rs) bone images

phase 4- (24hrs) differentiates Osteomyelitis from adjacent cellulitis

RSD shows positive phase 3 not correlation to phase 1/2

35
Q

What effects CRPS outcome?

A

Successful early diagnosis

36
Q

What is the TX of CRPS?

A

Non operative:

Analgesia- refer to pain team early: NSAIDs, alpha blocking agents( phenozybenzamine), antidepressants, anticonvulsants, GABA agonists, Ca channel blockers. bisophonates for osteopenia.

Physical therapy- gentle stretchings ( type 1), tactile discrimination training, graded motor imagery,

Nerve stimulation- only for type 2 if one nerve effected can place on that nerve area

Chemical sympathectomy- when other consx tx fail

Surgical

Sympathectomy- failed consx mx

vascular disorders hand (1 decks)

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