Mrc - Upper Extremity

Front 1

anatomy of APL and DeQuervains

Back 1

APL often has two slips, and sometimes slips are in separate compartments; for 1st dorsal compartment release both slips must be released

Front 2

intersection syndrome

Front 3

EIP anatomy

Back 3

distal-most muscle belly in forearm extensor compartment is EIP; EIP is ulnar of EDC to index

Front 4

Juncturae tendon

Back 4

can miss tendon laceration to extensor of index because EDC to long finger has juncturae that can extend index

Front 5

Sagittal band

Front 6

Lumbrical anatomy

Back 6

arise from radial side of FDP; pass volar to transverse metacarpal ligament; extend IP joints through lateral bands

Front 7

central slip

Back 7

EDC, inserts on base of middle phalanx; extend DIP

Front 8

Transverse retinacular ligament

Back 8

prevents dorsal subluxation lateral bands; becomes a swan neck deformity if volar plate laxity of PIP

Front 9

Triangular ligament

Back 9

stabilizes lateral band and keeps in position; if this is attenuated and central slip is ruptured, get boutoniere

Front 10

Oblique retinacular ligament

Back 10

starts on flexor tendon sheath, attaches on DP extensor tendon sheath; helps extend DIP

Front 11

Extensor tendon zones (1-9)

Back 11

Odds are over joints, even is over shaft

Front 12

Position of flexor tendons in carpal tunnel

Back 12

3&4 over 2&5 (ring and long are more volar- first ones you see in carpal tunnel release)

Front 13

Quadrigia effect

Back 13

if over tension one of FDP, get laxity of other tendons- Long, ring, small have single muscle belly in FDP

Front 14

Most important pulleys

Back 14

A2 and A4; if lost you decrease moment arm and decrease motion

Front 15

What is camper’s chiasm?

Back 15

where FDP passes through two slips of FDS

Front 16

Flexor zones?

Back 16

zone II is proximal edge of pulleys (distal palmar crease) to insertion of FDS, zone IV is carpal tunnel

Front 17

Horse-shoe abscess

Back 17

Ulnar and Radial bursa communicate at Parona’s space in 50-80% of people

Front 18

Midpalmar and thenar space delineation?

Back 18

midcarpal septum

Front 19

Thenar muscle innervation?

Back 19

All median nerve innervated except adductor and FDB (ulnar head is ulnar, radial head is median)

Front 20

What is main contributor to deep palmar arch?

Back 20

radial artery

Front 21

In the finger, orientation of nerve to artery?

Back 21

Nerve is volar to artery; in the palm, artery is volar to the nerve

Front 22

Orientation of Grayson’s and Cleland’s ligament

Back 22

Grayson’s is volar relative to Cleland’s ligaments; Grayson’s involved in Dupuytren’s

Front 23

What is Martin-Gruber anastamosis

Back 23

in forearm motor and sensory crossover (median and ulnar nerve); 15-20% of population <possible to have median nerve laceration in forearm but still have thenar function>

Front 24

Neuropraxia

Front 25

Axonotmesis

Back 25

axon disrupted but neural tube intact allowing growth of nerve

Front 26

Neurotmesis

Back 26

complete disruption of nerve; needs surgical repair

Front 27

Most important prognostic factor in nerve injury?

Back 27

Young age

Front 28

Size of nerve and type of repair

Back 28

larger mixed nerves such as ulnar nerve at elbow, and median nerve at wrist = do fascicular or group fascicular repair; digital nerve = conduit repair or epineurial repair

Front 29

dealing with nerve defects

Back 29

can use conduit for defects <4mm; or nerve graft such as sural nerve

Front 30

What study can help determine pre vs post-ganglionic brachial plexus

Back 30

SSEP’s

Front 31

Timing for brachial plexus surgery

Back 31

if no surgery after 3-6 months for; if root avulsion do ASAP

Front 32

Oberlin’s Transfer for upper nerve root injury

Back 32

FCU fascicle (C7) to musculocutaneous nerve for biceps function

Front 33

What nerve transfer for suprascapular nerve injury?

Back 33

CN XI to suprascapular nerve can help with shoulder function

Front 34

Priority for brachial plexus injury...

Back 34

Elbow flexion, followed by stable shoulder, followed by hand function

Front 35

Double crush syndrome

Back 35

compression neuropathy combined with proximal insult (especially c-spine)

Front 36

Median nerve compression sites

Back 36

AIN compression at , pronator syndrome, carpal tunnel syndrome

Front 37

Most reliable exam test for carpal tunnel?

Back 37

Carpal tunnel compression test (89% sens, 96% specific)

Front 38

Nerve conduction findings in carpal tunnel

Back 38

Distal motor latency > 4.5 msec; Distal sensory latency > 3.5 msec; also decreased amplitued.

Front 39

EMG changes in carpal tunnel

Back 39

fibrillation at rest

Front 40

Steroid injection and night splint efficacy

Back 40

80% short term relief; and after 12 months only 22% symptom free

Front 41

Indications for surgery in carpal tunnel syndrome

Back 41

non-op tx, thenar weakness, atrophy, positive EMG

Front 42

How to avoid variants in recurrent motor branch median nerve anatomy?

Back 42

want to divide transverse carpal ligament in line with ulnar side of ring finger, which is ulnar-most side of carpal tunnel

Front 43

Differentiating pronator syndrome from CTS:

Back 43

proximal forearm pain and decreased sensation in palmar cutaneous nerve distribution in pronator syndrome

Front 44

AIN syndrome

Back 44

Purely motor; may be compressed by deep head of pronator teres, origin of FDS, FCR, or Gantzer’s Muscle (accessory head of FPL)

Front 45

Gantzer’s Muscle

Back 45

accessory head of FPL that can cause AIN syndrome

Front 46

Ulnar nerve sites of compression at the elbow

Front 47

Cubital tunnel syndrome: Tx

Back 47

release without transposition

Front 48

Wartenberg’s sign

Back 48

Weak adduction of small finger leading to abducted digit due to overpull of abductors

Front 49

Guyon’s canal: causes

Back 49

very common to have a mass effect (ganglion, hamate Fx, ulnar artery thrombosis or aneurysm);

Front 50

PIN syndrome: sites of compression

Back 50

ECRB, Arcade of Froshe, Leash of Henry vessels

Front 51

Radial Tunnel Syndrome

Back 51

pain syndrome (no motor defecit); compression sites similar to PIN

Front 52

Wartenberg’s syndrome

Back 52

sensory radial nerve travels between brachioradialis and ECRL tendons; paresthesias in dorsal radial hand w/ positive Tinel’s

Front 53

What do you do acutely in diagnosed AIN palsy with weakness?

Back 53

observe, vast majority come back

Front 54

Most common cause of persistent symptoms after carpal tunnel release?

Back 54

incomplete release of transverse carpal ligament

Front 55

Tendon transfer for EPL rupture

Back 55

EIP transfer to EPL

Front 56

Principles of donor selection

Back 56

match qualities of donor muscle/tendon to the muscle being replaced (Force, amplitude, direction)

Front 57

Radial nerve innervates

Back 57

Triceps, anconeus, brachioradialis, ECRL, ECRB (high radial nerve injury would knock some of these out)

Front 58

Brand Transfer for high radial nerve palsy

Back 58

pronator teres to ECRB (wrist extension); FCR to EDC (finger flexion); Palmaris longus to EPL (mostly tenodeses thumb out of palm)

Front 59

For PIN loss, what transfers are needed

Back 59

Same as “Brand transfer”, except wrist extension is maintained, so no pronator teres to ECRB needed

Front 60

Common opponensplasties

Back 60

EIP around ulnar side of wrist; Huber transfer ADM to ABP

Front 61

High median nerve injury (includes AIN) and tendon transfers

Back 61

opponensplasty of some sort, plus side to side transfer of FDP to long and index (median) to FDP to ring and small (ulnar innervated); and Brachioradialis to FPL

Front 62

Distal radius

Front 63

Ulnar styloid fratures

Back 63

multiple studies say you do not have to fix these; many go on to asymptomatic fibrous union; however if gross instability after plating DRUJ, probably should plate

Front 64

Darrach procedure

Back 64

excision of ulnar head (do only in elderly)

Front 65

Suave-Kapandji procedure

Back 65

DRUJ fusion and proximal ulnar resection to develop pseudarthrosis

Front 66

Pronation and supination and ulnar variance

Back 66

Pronation leads to relatively positive ulnar variance; Supination leads to relatively negative ulnar variance

Front 67

Scaphoid blood supply

Back 67

distal to proximal on the dorsal side

Front 68

Scaphoid: radiography

Back 68

get navicular view; oblique view; clenched fist view; MRI very reliable; Bone scan will become positive at 72hrs

Front 69

Non-union rate in scaphoid Fx

Back 69

Delay in treatment < 28 days = 5% nonunion; delay in treatment > 28 days = 45% nonunion

Front 70

Indications for ORIF scaphoid

Back 70

displacement > 1mm, proximal pole fracture

Front 71

SNAC wrist (scaphoid non-union advanced collapse): describe sequence

Front 72

DISI (dorsal intercalated segmental instability): describe

Back 72

disruption of scapholunate interosseus ligament; scaphoid typically helps flex the lunate; leads to SLAC wrist

Front 73

VISI (volar intercalated segmental instability): describe

Back 73

disruption of lunato-triquetral interosseous ligament; SL angle < 30 with flexion of lunate; symptomatically will have ulnar sided wrist pain

Front 74

Watson’s test for S-L instability

Back 74

for scapholunate instability; push on scaphoid tubercle with wrist ulnarly deviated, then have patient radially deviate- will feel scaphoid subluxation and pt experiences pain

Front 75

SLAC wrist (scapho-lunate advanced collapse): describe sequence

Back 75

Stage I = radial styoid + distal scaphoid DJD, II = proximal and distal scaphoid DJD, III = proximal migration of capitate and CL DJD, IV = diffuse DJD

Front 76

Greater arch injury of wrist

Back 76

Trans-scaphoid, Trans-capitate, perilunate dislocation;

Front 77

Perilunate dislocations: Tx

Back 77

Emergent reduction; all need surgery semi-urgently (within a few days); no role for closed treatment

Front 78

How to immobilize MP and PIP joints and why

Back 78

MP in flexion to avoid collateral tightness; PIP in extension to avoid volar plate tightness

Front 79

Metacarpal neck fracture angulation

Back 79

Index and long < 20 degrees; Ring <40; Small <70

Front 80

Indication for ORIF interfrag screws in phalanx or metacarpal fractures

Back 80

If fracture is oblique with fracture length 2x bone diameter

Front 81

Dorsal dislocations of PIP

Back 81

buddy tape x 4 weeks

Front 82

Volar dislocation of PIP

Back 82

central slip disruption; if unstable after reduction- pin x 3 weeks; total time in extension immobilization is 6 weeks (to avoid boutoniere)

Front 83

PIP fracture dislocations

Back 83

Stable if < 30% - may immobilize with dorsal extension block splint in adequate flexion to reduce fracture; if >30% needs surgery

Front 84

Pilon fractures of PIP base

Front 85

Bennett Deforming forces

Back 85

Abductor Pollicis Longus proximal pull (primary deforming force); also Abductor Pollicis Brevis (supinates Fx) and Adductor Pollicis Brevis (pulls distal fracture site ulnarward)

Front 86

Acute thumb UCL injury: Tx

Back 86

if >35 degrees angulation on stress view it is complete; complete tears often associated with Stener lesion; all complete injuries need surgery; incomplete may be immobilized

Front 87

Compartment syndrome of the hand

Back 87

release interosseous compartments through 2 dorsal incisions, and thenar and hypothenar

Front 88

Volkman’s ischemic contracture

Front 89

Intrinsic minus

Front 90

Intrinsic plus

Front 91

Most commonly involved muscles in forearm compartment syndrome

Back 91

FDP and FPL

Front 92

What to repair nail bed with:

Back 92

6-0 or 7-0 absorbable

Front 93

Finger tip injury with pulp or tip loss with no exposed bone: Tx

Back 93

non-op tx, thenar weakness, atrophy, positive EMG

Front 94

Finger tip injury: volar oblique with skin loss

Back 94

cross finger flap; adjacent finger take dorsal skin and sub-Q, and sew to injured digit; take down pedicle at 3 weeks

Front 95

Flap for transverse thumb amputation

Back 95

Moberg advancement flap

Front 96

Finger tip injury with exposed bone dorsal oblique: Tx

Back 96

V-Y advancement

Front 97

Amputated finger tip in child < 6 y/o

Back 97

may sew back on as ‘composite graft’; but notify parents it probably will not live and serves only to cover wound

Front 98

Lumbrical plus finger and traumatic amputations: explain

Back 98

paradoxical extension of IP joint during finger flexion; FDP lacerated and retracts causing tension (through lumbrical) on extensor mechanism; treatment is release of lumbrical

Front 99

Best type of skin graft for volar palm

Back 99

full thickness

Front 100

Can you skin graft over exposed tendon (no paratenon)?

Back 100

No- you must do flap (dorsal finger need to do 1st dorsal metacarpal flap)

Front 101

Absolute indications for replantation

Back 101

Thumb, any amputation in child, wrist or proximal, multiple digits

Front 102

Contraindication to replantation

Back 102

Zone II, single digit, polytrauma patient, crush/avulsion, segmental injury, multiple medical problems, prolonged ischemia

Front 103

Replant operative sequence

Back 103

Bone, tendons, arteries, nerves, veins, skin

Front 104

What anticoagulant do leeches have in saliva.

Back 104

Hirudin- useful for minimizing venous congestion in replants

Front 105

What bacteria do leeches carry and what Abx must be used?

Back 105

Aeromonas hydrophila; Flouroquinalone

Front 106

Indication for extensor tendon repair

Back 106

if laceration > 50%

Front 107

Tx bony or soft tissue mallet finger

Back 107

6-8 weeks extension splinting; ORIF if fragment > 50% or if there is subluxation

Front 108

Rupture of radial sagittal band at level of MTP

Back 108

Often have ulnar subluxation of EDC, resulting in extensor lag; Tx: extension splinting of MP (rare indication for this) or repair sagittal band

Front 109

Intrinsic tightness

Back 109

limited PIP flexion due to intrinsic tendon tightness; PIP flexion limited with MP hyper-extension

Front 110

Extrinsic tightness

Back 110

limited PIP flexion secondary to extensor tendon tightness ; PIP flexion improves with MP hyperextension

Front 111

What part of extensor mechanism do lumbricals attach?

Back 111

radial lateral band; in lumbrical plus finger it is the radial lateral band that is actually released

Front 112

Key factors in flexor tendon repair strength:

Back 112

directly proportional to number of strands in core suture; grasping suture technique; epitendinous repair increases strength by 10-50%.

Front 113

Sang’s choice in flexor tendon repair

Back 113

4-0 fiberwire with four strand cruciate technique, epitendinous with 6-0 nylon

Front 114

Flexor tendon rehabilitation guidelines

Back 114

dorsal block splint x 6 weeks with 30 degrees wrist flexion, 70 degrees MCP flexion; passive flexion (rubber bands), active extension x 4 weeks, then can gradually start active flexion

Front 115

Chronic Jersey Finger (FDP avulsion) if FDS intact: Tx

Back 115

do not repair FDP; if necessary could fuse DIP

Front 116

In what situation do you get quadrigia effect?

Back 116

FDP advancement of > 1cm; this is a flexor lag in adjacent digits (FDP to long, ring, and small)

Front 117

In what digit can you not develop a quadrigia effect?

Back 117

Index finger- the only FDP tendon with its own muscle belly

Front 118

What do you do for chronic paronychia?

Back 118

marsupialization and sometimes nail removal; these are often due to candida albicans

Front 119

Kanavel’s sign

Back 119

fusiform swelling, tender to palpation along flexor sheath, pain with passive motion, flexed resting posture

Front 120

Fight bite organism

Back 120

Eikanella corrodens; treat with I&D and Augmentin

Front 121

Spiral bands and spiral cords in dupuytren’s

Back 121

Spiral bands become spiral cords, which often draw neurovascular structures volarward

Front 122

Dupuytren’s Diathesis

Back 122

Plantar fibromatosis, knuckle pad involvement IPIP), penile fascial involvement

Front 123

First finger to typically be involved in Dupuytren’s

Back 123

Ring finger, followed by small finger

Front 124

Diseased cell type in Dupuytren’s?

Back 124

proliferation of myofibroblasts in palmar fascia

Front 125

Dorsal ganglion cyst origin

Back 125

scapho-lunate in 70%

Front 126

Lateral epicondylitis: description and Tx

Back 126

tendinosis of ECRB; treatment is debridement of ECRB

Front 127

Type III thumb hypoplasia

Back 127

type III A (stable MP- reconstructable); IIIB (unstable MP- not reconstructable)

Front 128

Type I thumb hypoplasia

Back 128

opponensplasty

Front 129

Type II thumb hypoplasia

Back 129

Web deepending, MCP UCL reconstruction

Front 130

Type IV thumb hypoplasia (ponce flottant): Tx

Back 130

amputation and Pollicization of index

Front 131

Polands Syndrome

Back 131

Absence of pectoralis major, unilateral; associaed with Symbrachydactyly

Front 132

Distal humerus Fx in patients >65 y/o

Back 132

fix if you can get stable fixation and permit early motion; if very comminuted, should do total elbow arthroplasty

Front 133

Essex Lopresti associated injuries

Back 133

DRUJ instability with radial head fracture; (central third of inter-ossesus membrane most important in decreasing axial stability)

Front 134

Associated injuries with radial head fractures

Back 134

DRUJ (essex-lopresti), rupture MCL, elbow dislocation/radial head/coronoid; olecranon Fx/dislocation

Front 135

Indication for ORIF radial head

Back 135

If articular stepoff >3mm

Front 136

Indication for replacement radial head

Back 136

if comminuted in more than 3 fragments; if >25% of articular surface lost, replace radial head

Front 137

Coronoid Fractures: significance

Back 137

in the setting of elbow dislocation, coronoid should be fixed

Front 138

Significance of anteromedial facet of coronoid

Back 138

associated w/ LCL injury and leads to varus postero-medial rotatory instability

Front 139

Elbow dislocation: indications for acute surgery

Back 139

if associated coronoid or radial head fractures (II-III); instability within 30 degrees of extension

Front 140

Structures at risk with anterior elbow portals

Back 140

med antebrachial cutaneous nerve, ulnar nerve, median nerve, brachial artery

Front 141

Insertion of anterior band of UCL

Back 141

sublime tubercle

Front 142

Dynamic stabilizers of elbow

Back 142

Flexor and Extensor origins, and anconeus

Front 143

Postero-lateral rotatory instability

Back 143

Lateral ulnar collateral ligament injury; instability in supination and valgus stress; (radial head goes posterior)

Front 144

Lateral pivot shift test

Back 144

patient lays prone, you do axial compression and valgus on flexed, supinated forearm, and feel for subluxation

Front 145

Valgus instability

Back 145

if ulnar collateral ligament alone is injured w/o radial head Fx, no treatment needed except if throwing athlete

Front 146

Functional ROM of elbow

Back 146

30-130 degrees

Front 147

Indication for HO prophylaxis in elbow

Back 147

no defined literature, but incidence of Head + elbow injury HO 75-85%

Front 148

Indications for elbow capsular release

Back 148

if ROM worse than 40-105; also should do ulnar nerve transposition at time of capsular release

Front 149

indication for elbow arthrodesis

Back 149

severe DJD with intractable sepsis in patients and no hope for total elbow

Front 150

indication for unlinked (unconstrained )total elbow

Back 150

osteoarthritis in patients with intact LCL and good bone stock

Front 151

Wrist position to cast if suspected DRUJ injury (Galeazzi/Essex-Lopresti)?

Back 151

Splint/cast in supination

Front 152

Position to cast post elbow dislocation (postero-lateral rotatory instability)?

Back 152

Cast x 2 weeks in pronation and 90 deg flexion, then d/c immobilization and start motion

Front 153

Interval for dorsal (Thompson) approach to radius?

Back 153

ECRB and EDC, and deep through two heads of supinator; PIN is within substance of supinator

Front 154

Sites of compression in radial tunnel syndrome

Back 154

between radio-capitellar joint and supinator (FREAS); Fibrous bands radio-capitellar join; Recurrent radial artery branches (Leash of Henry), ECRB, Arcade of Frohshe, distal edge of supinator

Front 155

Dupuytren’s Indications for Surgery

Back 155

MCP flexion contracture >30 degrees, any PIP contracture (this is related to concerns about development of PIP volar plate contracture)