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FESSH exam 2022 > Wrist > Flashcards

Wrist Flashcards

1
Q

Column concept

A

Lateral - S,T,T bones (mobile)

Central - L,C,H bones (flex ext)

Medial - Triquetrum and distal carpal row , rotation

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2
Q

Space of Poirier

A

Between volar RSC and volar long radiolunate (radiolunotriquetral), at the base of Capitate

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3
Q

Volar radoiocarpal lig

A

RCL - Radial collateral
RSC - Radioscaphocapitate
Long radiolunate
RCL - Radioscapholunate (Testut and Kuentz) not at true lig, neurovascular
Short RL - Radiolunate

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4
Q

Volar ulnocarpal lig

A

Ulnotriquetral
Ulnolunate
Ulnocapitate

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5
Q

Dorsal lig

A

Radiotriquetral (disruption + lunotriquetral big rupture gives VISI)
DIC - Dorsal intercarpal
RL - Radiolunate
RS - Radioscaphoid

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6
Q

Proximal row intrinsic lig

A

Scapholunate lig
Lunotriquetral lig

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7
Q

distal row ligaments

A

Trapeziotrapezoid lig
trapeziocapitate lig.
Capitohamate lig.

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8
Q

Palmar midcarpal lig

A

Scaphotrapeziotrapezoid STT
Scaphocapitate
Triqutralcapitate
Triguetralhamate

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9
Q

Colle fracture
Indication for surgery

A

> 10-15 Degrees dorsal tilt
2-5 mm ulnar shortening
2 mm intraarticular step-off
<15 degrees radial inclination

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10
Q

Lunate types

A

Type 1: One distal facett (to capitate)
Type 2: Two facettes (Capitate and Hamate)

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11
Q

How does lunate type affect Kienböck disease?

A

Lunate type 2 (2 facettes) seems to be protective against DISI and coronal fractures in Kienböck

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12
Q

Etiology of Kienböck

A

Avascular necrosis
1. Biomechanical factors (Ulna negative, Decreased radial inclination, repetetive trauma)
2. Anatomic factors (Lunate 1 predisposed, vascular)

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13
Q

Kienböck type IIIA and B difference

A

Important difference in treatment.
A: Early collapse with no fixed scaphoid rotation (treatment to prevent further collapse)
B: Late collapse with fixed rotation (too late - only pain reducin procedures)

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14
Q

Kienböck stage IV

A

Arthritis adjacent joints

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15
Q

Kienböck type I and II (of IV)

A
  1. MRI (not visible on x-ray)
  2. Sclerosis
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16
Q

Kienböck stage 1 treatment

A

NSAID
Immobilisation

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17
Q

Kienböck stage 2 and 3A treatment (5)

A
  1. Joint levelling (radial shortening)
  2. Radial wedge osteotomy
  3. STT-fusion
  4. Distal radius core decompression
  5. Revascularization procedures
  6. Capitohamate fusion + SC fusion (66% decreased contact stress on lunate)
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18
Q

Kienböck stage 3B treatment

A
  1. PRC
  2. STT-fusion
  3. SC-fusion
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19
Q

Kienböck stage 4 treatment

A
  1. Wrist fusion
  2. PRC
  3. Limited intercarpal fusion
  4. Total wrist arthroplasty
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20
Q

Role of MRI in Kienböck

A

Early diagnosis
Rule out ulnar impaction
(decreas T1 signalling)

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21
Q

Role of CT in Kienböck

A

Once collapse has already occured
1. Extent of necrosis
2. Lunate geometry
3. Trabecular destruction
4. Degenerative changes

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22
Q

Vascularized bone graft for Kienböck disease?

A

Many options have been described including
- transfer of pisiform
- transfer of distal radius on a vascularized pedicle of pronator quadratus
t- ransfers of branches of the first, second, or third dorsal metacarpal arteries
- 4 + 5 extensor compartment artery (ECA)

+ temporary pinning of the STT joint, SC joint or external fixation may be used to unload lunate after revascularization

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23
Q

TFCC inj classification

A

Palmer classification
1 acute
A central
B ulnar
C distal
D radial

2 degenerative
A thinning
B chondromalac
C perforation
D LT lig perforation
E arthritis

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24
Q

Ulnar impaction treatment

A

Wafer (2-4mm if no instability, open or arthroscopically

Ulnar shortening in diaphysis prox to DOB lig

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25
Q

Two typer of ulnocarpal dislocation

A
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26
Q

Radial inclination and palmar tilt?

A
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27
Q

2 dorsal and 6 volar extrinsic wrist ligaments

A
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28
Q

In radial deviation, does the scaphoid flex?

A
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29
Q

Funktion of triquetrum in the wrist

A
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30
Q

How do u see that its a true lateral?

A

The pisiform is between the capitate and the scaphoid

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31
Q

3 ulnar extrinsic volar lig

A
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32
Q

3 volar radial extrinsic lig

A
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33
Q

An importens funktion of DIC lig

A
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34
Q

2 dorsal extrinsic lig

A
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35
Q

Mechanism of SL rupture?

A

Volar short RL lig intact Hilda lunatum
Firat volar SL then dorsal

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36
Q

How does the lunate dislocate?

A
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37
Q

Tales IK type 2 is?

A
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38
Q

Signs of VISI in a frontal

A

Seagull sign, ring sign, sec SL dissociation(not true)

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39
Q

Lesser arc perilunate dislocation means?

A

Only ligament inj

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40
Q

Greater arc perilunate injury

A
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41
Q

Ulna carpal dislocation type 2?

A
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42
Q

Mayfield stage 1

A
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43
Q

Mayfield stage 2?

A
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44
Q

Mayfield stage 3

A
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45
Q

Mayfield stage IV

A
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46
Q

When is it possible to reconstruct SL-injury

A
  1. Reducible SL in frontal/lateral
  2. Stable lunate, not ulnarly translated(short/long RL intact)
  3. Patient factors
  4. Local exprience/complications
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47
Q

Unstable lunate + SL, what to do?

A

Spiral antipronation tenodesis (FCR borras igenom S, går dorsalt om L till T och sen volart om L till radiusstyloiden där den förankras)

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48
Q

SCAC?

A

Scaphoid Chondrocalcinosis Advanced Collapse (pyrofosfate deposition - extremely common)

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49
Q

SLAC 1

A

Arthrosis in dorsal part of scaphoid fossa

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50
Q

SLAC 2

A

Large dorsal damage of scaphoid fossa

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51
Q

SLAC 3

A

Midcarpal
Never affects SCj (as in SNAC)
But with DISI dorsal LC degenerates

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52
Q

SNAC movement of S?
Snac1

A

Distal fragment is flexed and rotated (pronated)
Distal fragment has more motion than unbroken
SNAC1 - affects radial styloid fossa not proximal S - fossa

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53
Q

SNAC 2

A

Between proxiaml fragment and Capitate not distal fragment. The distal fragment moves together with C. The proximal fragment moves together with L (not affecting l and prox S fossa)

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54
Q

SNAC 3 and SLAC 3

A

Affecting LC joint dorsally with DISI

55
Q

SNAC and SLAC 4

A

THj osteoarthritis - extremely uncommon

56
Q

SCAC pattern

A

Difference from SLAC is calcinosis, no Scaphoid flexion, Scapiod is usually digging into radius (often Sl injury - missdiagnosed as SLAC)

57
Q

Factors influencing outcomes of PRC

A

> 40y
Not heavy job
Type of capitate/lunate did not affect clinical outsomes

58
Q

PRC indications

A

ONLY in SLAC 1 and 2 and SNAC 1 (all others affect head of capitate)

Otherwise 4CF in stage 3 SLAC, stage 2 SNAC

59
Q

PRC and 4CF tips

A
  • Preserve RSC radioscaphocapitate lig
  • Small radial styloidectomy prevents radio-trapezoid impingement
  • 4CF derotate lunate
60
Q

Tips RSL fusion

A

Inspect midcarpal
Excise distal 1/4 Scaphoid (improves unoin rates, maximises DTM)
POP 4 weeks, Wires out later

61
Q

2 STT fusion tips

A

Restorenormal hight!
Scaphoid angle 55-60 degrees important

62
Q

Why is total arthroplasty not a winner?

A
  • Closer to the body better results (cannot be compared to other joints)
  • Strong rivals (Fusion, PRC..)
  • Limited indications (gives less money to develop)
63
Q

3 Types of wrist implants now?

A
  1. Freedom
  2. Re-motion
    Cementless - distal polyethyleene, ellipoid,
  3. Motec (Ball and socket, no cement into radius, capitate and 3rd MC)
64
Q

Most common cause of failiure in implants

A

Distal component loosening,
often stuck proximal and difficult to take away

65
Q

Lunate vascular necroris cause

A

Stress fracture in subchondral bone gives a compartment syndrome in the bone with damaged venous drainage - but cartilage is preserved in early disease! It’s a bone disease

66
Q

Morphologic causes of Kienböck

A

-Short ulna (stress fracture in the radial half of lunate)
- Viegas type 1 (1 distal facet)
- Zapico 1 (<130gr)

67
Q

Kienböck mechanical effects?

A
  • Collapse of lunate gives prox migration of Capitate - like cracker into SL and collapse of central column
  • Kissing lesions LC and RL osteoarthritis
  • S flexion
  • T extension
  • Carpal ulnar translation
68
Q

Kienböck classifications

A
  1. Lichtmann (MRI nad radiography)
  2. Schmitt (staging viability with MR + gadolineum)
  3. Bain (arthroscopic assessment (0-4)
  4. 4D CT
69
Q

<15y Keinböck treatment?

A
  1. Konservative 6m
    If proceeds surgical levelling procedure:
  2. Epiphysiodesis with or/without carpal central loading decompression
  3. STT pinning temporary
70
Q

> 70y Kienböck treatment

A

Conservative since good clinical outcome even if the disease progresses
Arthroscopic synovectomy for pain

71
Q

Kienböck with intact lunate treatment - protect fr loading

A

Only extraarticular procedures

If short ulna -> radial wedge osteotomy 2-3mm +/- STT pinning

Not short ulna but increased radial tilt - radial wedge osteotomy

Not short ulna -> 2-3mm Capitate shortening +/- STT-pinning

72
Q

Kienböck with compromised lunate - treatment (still reconstructable 2 and 3A)

A

Reconstruction - intraarticular procedures

  1. Cancellous graft
  2. Vascularized graft
  3. Tissue transfer
73
Q

Kienböck not reconstructible lunate - treatment

A

Salvage to reduce pain and restore hand function after athroscopic assessment:
1. intact RLj -> PRC
2. damaged RLj but intact RSj -> SC-arthrodesis

74
Q

Static forearm stabilizers

A
  • PRUj lig
  • Proximal oblique cord
  • Central band (most important) & accessory bands
  • Distal oblique bundle
  • DRUj & ulnocarpal lig
75
Q

Central band of Interosseous lig direction and origin?

A

When walking on hands - load and prox migration of radius- Central band prevents this (orientation prox radius 1/3 to distal ulnae 2/3). often obvious tubercles on the bone

76
Q

Distal oblique bundle function?

A

Static stabilizer DRUJ (not everyone has it)

77
Q

Axis of forearm rotation?

A

Oblique from enter of radial head to basistyloid fovea of ulnar head

78
Q

Is ulna still under pro/sup?

A

No - slight motion (moves a little bit to the other side of the radius ex pronation moves ulnarly..)

79
Q

Where do you need congreuncy for forearm movement

A

Congruency of the whole forearm joint PRUJ, radial pronation so the radius can go over the ulna and DRUJ

The whole forearm is a joint

80
Q

Load transfer in wrist and elbow

A

20% ulna, 80% radius

20% goes from radius to ulna through the central band of interosseous membrane

In elbow 40% through ulna and 60% through radius

Depends on ulna +/i and pronation/supination
More equal load in supination to ulna and radius

81
Q

What is most important of longitudinal forearm stability

A
  1. Radial head most important
  2. CB central band sec stabilizer
  3. TFCC less important

If no radial head the interosseous lig will have less tension since the bones are close together

82
Q

DRUJ stabilizers?

A

TFCC
Ulocarpal lig
IOM

Dynamic stabilizers:
ECU tendon and sheath
PQ
arm & forearm muscles

83
Q

DRUj LAXITY exams?

A
  1. Piano key sign (man ska tryck på ulna som en piano tangent)
  2. Dimple test (det jag tidigare trodde var piano key
  3. Distal ulna ballottement test (neutr, pro, sup, radial incl testing ulnocarpal lig)

If patient can dynamically stabilize the DRUj it can have laxity but still be stable.

84
Q

How to treath DRUJ arthropaty

A
  1. Resection
  2. Fusion (Sauve-Kampandji)
  3. Arthroplasty (Herbert, Schecker)
85
Q

Ulnar pain exams

A
  1. TFCC/ulnar grinding test (wrist extension, load and rotate to uln dev)
  2. Press test (ställa sig upp o belasta)
  3. Radioulnar compression test
85
Q

6 groups of ulnar sided wrist pain (Lluch and Garcia Elias)?

A

Intracapsular
1. DJUR articular (synovitis, arthropathy, stiffness
2. Lig inj
3. Impaction syndr
4. Carpal instab
5. Other carpal conditions

  1. Extracapsular causes
86
Q

Treatment of DRUj artropathy?

A
  1. Resection or hemiresection (Darrach)
  2. Fusion (sauve Kampandji)
  3. Arthoplasty (Herbert, Schecker
87
Q

Impaction syndromes types and treatment

A

Ulnocarpal
- Constitutional or aquired

Ulnar styloid-triquetrum impaction syndrome
- Megastyloid
- Non-union of ulna styloid

Luno-hamate and triquetro-hamate

Radio-ulnar impaction after Darrach resection

88
Q

Ulnar shortening tnesion what?

A
  1. Ulnocarpal lig (UTr and UL)
  2. Distal oblique bundle of IOM (not always present)
89
Q

Ulnar styloid triquetrum impaction test

A

Supination - extension - ulnar deviation

Puts styloid the closes to triquetrum

Can be impingement of bony part or the ulnocarpal soft tissues a.k.a. ulnocarpal meniscoid

90
Q

Ulnocarpal meniscoid impingement test

A

press fovea and ulnarly deviate wrist

91
Q

Ulnocarpal impingement treatment

A

Ulnocarpal
- Constiutional och acquired (secondary to DRF malunion)

Treatment if no osteoarthritis?
- Radial lengthening
- Ulnar shortening (if not secondary abutment)
- Distal ulnar resection (Wafer by Feldon et al -92) keeping DRUj

92
Q

Carpal instabilities

A

CIND - Carpal Instability Non Dissociative - between carpal rows (Palmar midcarpal instability) - often with clunk

CID - Carpal Instability Dissociative (Lunotriquetral instability)

93
Q

Difference betweend CIND and CID

A

CIND is between carpal rows
CID is within a carpal row

94
Q

Mention 3 “other” intracapsular conditions caousing ulnar sided wrist pain

A
  1. Kienböck
  2. Chondrocalcinosis
  3. Painful tumours like osteoid osteoma
95
Q

Extracapsular causes of ulnar sided wrist pain

A

25%
1. Tendinopathies (mostly ECU and sheet that is very innervated, or FCU pisiform insertion)
2. Other joints and bones (pisiform, hamate hook fx, PTr joint
3. Nerve and vascular (nerve inj or in Guyon canal)

96
Q

ECU tests

A
  1. ECU synergy test (Supinate and abduct fingers)
  2. ECU tendon subluxation test “Sand scoop test” (supinate ulnar dev and palpate ECU)
97
Q

Where does the limbs of TFCC attach

A

Deep limb to fovea
Superficial to ulnar styloid

98
Q

How much pro/supination is radiocarpal

A

30 degree

150-180 in DRUj

99
Q

Stabilizers of DRUj

A

TFSS
IOM
DRUj capsule
Articular disk
Dynamic: PQ & ECU

100
Q

Meniscus Homologue

A

Structure prox to and attached totriquetrum. Well vascularized loose connective tissue fr synovium

101
Q

How to confirm correct lateral x-ray view

A

SPC-lateral
From palmar the palmar surface´s of Scaphoid, Pisiform, Capitate should come in this order

102
Q

TFCC reconstruction if repair not possible

A
103
Q

Sigmoid notch osteoplasty

A

+ bone graft

104
Q

Difference of ulnar vaiance in pro/supination

A

Only 0,6mm

But still most ulna plus in pronation, power grip or combo

105
Q

When is ulnar shortening a good option for DRUj problems?

A

If radial shortening is the only substantial deformity and articular alignment of the radius and carpus is satisfactory

106
Q

How many cadavers have TFCC perforationin normal and ulna + wrist compared to ulna minus

A

73% vs 17%

Radiography in pronation and powergrip - can give 2mm ulnar variance

107
Q

How much of the distal head should be wxcised in Wafer procedure
by Feldon and co

A

2 - 4 mm

Concider ulna-shortening osteotomy - doeas not violate joint

108
Q

Hemiresection- Interposition arthroplasty

A

Bowers arthroplasty

If intact TFCC
DRUj osteoarthritis
And ulnar head shortening osteotomy is possible. They prefer metafyseal with good healing attached with anchor

109
Q

How many mm ulna-shortening

A

Ulna + -> 0 och -1

Ulna neutral -> 2-3 mm

110
Q

Approach to DRUj
and to TFCC

A

5th compartment

between FCU and ECU

111
Q

How much excise in Sauve-Kapandji?

A

1cm

If ulna positiv -> correct it and resect more so 1cm gap in pseudoarthrosis

FCU distal tenodesis + Interpose detached ulnar PQ in pseudoarthrosis

112
Q

Stabilization of respected distal ulna

A

FCU and ECU strips by Breen and Jupiter

113
Q

Where ostotomy for Darrach

A

At margin of sigmoid notch approx 3cm
Ulnar styloid + attachments left in situ

Risk ulnocarpal translation - considor RL fusion

114
Q

Ecu sheet reconstruction

A

Do not suture to itself but proximal to create a loose sling

115
Q

Oblique or transverse osteotomy in dorsal opening wedge DR osteotomy

A
116
Q

Volar marginal fragment

A

5 mm or less. Needs hook plate added, can be avascular. Watershed line is 2mm from joint but because of hardware thickness 5mm away is needed

117
Q

How to prevent going distal to water shed line

A

Make incision in PQ at the side and along the palpated water shed line to elevate all soft tissues

118
Q

Incision for volar plating

A

Extended FCR approach crossing the flexor sheet and follow FCR distally. Split FCR insertion to trapezium. Move FCR and FPL ulnarly. Maybe release FPL radial insertion. Release 1st compartment and BR step wise for suture afterwards.

119
Q

Why often problem intraop reduce dorsal tilted DRF fx

A

Dorsal organized hematoma inside periosteum. PRONATE the whole pro fragment. Lift periosteum if needed

120
Q

How to see proper reduction in DRF perop in PA

A

Use wires, the ulnar should exit in the ulnar corner and also a radial wire - before screws. Use additional x-ray angel

121
Q

How to see proper PLATE PLACEMENT in lateral

A

2mm from osteochondral limit.

122
Q

What is this view called and how to do it

A

For viewing DRUj screw penetration

123
Q

Blatt capsulodesis

A

If reducible SL dissociation

Dorsal capsular flap leaving radius origion, 1cm wide capsular flap insicion in scaphoid axis full length, developed from ulnar side
Reduce scaphoid Eric with wire to capitate and MC3- pill our suture trough fine drill Holes to volar tubercle.

124
Q

Bain and Begg classification

A

1 prox lugnare
2 lugnate fossa
2B fracture
3 distal lunate
4 próx capitate

125
Q

Zaidemberg

A

Mist common for avascular necrosis
1,2 iC SRA

126
Q

Approachens to both bone midshaft fracture

A
127
Q

Antipronation spiral tenodesis

A

If reducible ulnar translation in SL injury (3LT if only reducible SL gap)

128
Q

Staging SL-disability
Modified by Garcia Elias

A
  1. Partial
  2. Still Repairable but total
  3. Not repairable
  4. RS angle bad
  5. Is reducible but lunate malaligned
  6. Is not reducible
  7. Bad cartilage
129
Q

EWAS

A
  1. Elongation- probe no passage
  2. Tip of probe inside (próx membrane rupture)
    3A. 2 + volar SL (volar widening with probe)
    3B. 2 + dorsal (dorsal)
    3C. 2 + dorsal + volar (global widening but reduces when probe is out)
    • SL gap but no radiographic abnormalities (arthroscope through)
    • rtg anomalies
130
Q

Kienbock 3A and B difference measure

A

RS angle over 60 degrees by Goldfarb et al

131
Q

How to make osteotomy in distal radius malunion

A

Parallell to joint surface

132
Q

CIND surgery

A

Rehab, proprioception!

Volar CIND: RL fusion, but if good cartilage and easy reducible reconstruction with ECRB strip tunneled in C and Trq. No longer TrqH fusion because RS impingement.

Dorsal: No longer suture space of poirer because stops extension of wrist. Instead ex Mayo capsulodesis reinforcing DIC.

133
Q

Prognosis of conservative treatment of Kienböck

A

Kristensen et al, 46 pat mean 20y: 66% arthritis but 20% significant symptoms

Taniguchi - worse rig in 70% of 20 pat 25y but 20% sign symptoms

Keith 33 pat predictable pattern of worsening incl DASH

FESSH exam 2022 (12 decks)

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