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45 Cards in this Set

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What are the typical areas involved in rheumatoid arthritis?
cervical spine, shoulders, elbows, hands, hips, knees and feet
What is the pathophysiology of rheumatoid arthritis?
Inflamed synovium invades and destroys articular cartilage
What is the female:male ratio in rheumatoid arthritis?
3:1
Patients with rheumatoid arthritis need what special pre-op evaluation?
cervical spine evaluation
In what order do you address joints in patients with rheumatoid arthritis?
proximal to distal
What are common hand findings in rheumatoid arthritis?
ulnar drift at the MCPs, caput ulna, swan-neck and boutonniere deformities, tendon ruptures, thumb deformities, radiocarpal collapse
What are the typical x-ray changes of rheumatoid arthritis?
periarticular erosions and osteopenia
What is the mechanism of ulnar drift at MCPs?
synovitis at MCP causes laxity, laxity causes ulnar deviation of the extensor tendons, radial deviation of the wrist and metacarpals alters the direction of pull of the extensor tendons
What is the surgical treatment for ulnar drift?
Address wrist first. If no joint destruction: synovectomy, soft tissue realignment and ulnar intrinsic release. If joint destruction: MCP implant arthroplasty
What is a caput ulna?
dorsal subluxation of the ulna due to distal radioulnar joint synovitis and capsule stretch
What is Vaughn-Jackson syndrome?
Ischemic or attritional rupture of finger extensor tendons due to dorsal ulnar subluxation
When is operative treatment indicated in the management of caput ulna?
Failure of medical management, pain with motion
What is a swan-neck deformity?
hyperextension of the PIP with flexion at the DIP
What are the 3 distinct mechanisms of the swan-neck deformity?
synovitis at the DIP leading to rupture of distal extensor tendon (mallet deformity); synovitis at PIP leading to volar plate laxity; or intrinsic tightness leading to MCP subluxations which causes extensor imbalance
Correction of swan-neck deformities depends on what 2 factors?
PIP joint mobility and destruction
If joint fusion is necessary in correction of swan-neck deformities, at what degree of flexion are the fingers fused?
index at 30 degrees, middle at 35 degrees, ring at 40 degrees and small finger at 45 degrees
What is a Boutonniere deformity?
flexion at PIP with hyperextension at the DIP and MCP
How do you correct a Boutonniere deformity when there is a fixed flexion deformity?
Arthrodesis vs. arthroplasty of the PIP
What are the 4 causes of a sudden inability of a rheumatoid patient to extend a finger?
1. extensor tendon rupture from attrition, 2. ulnar subluxation of an extensor tendon at the MCP, 3. posterior interosseous nerve palsy at the elbow, 4. palmar subluxation of the MCP
What is the most common extensor tendon to rupure in rheumatoid patients?
expensor pollicis longus
What is the most common flexor tendon to rupture in patients with rheumatoid arthritis?
flexor pollicis longus
What is Mannerfelt's syndrome?
Rupture of flexor pollicis longus
What are the physical findings associated with rupture of flexor pollicis longus?
inability to flex the thumb at the IP joint
What are the causes of rupture of flexor pollicis longus?
synovitis, carpal osteophyte
How do you treat rupture of flexor pollicis longus?
synovectomy, osteophyte resection and tendon graft or transfer
What is the most common form of arthritis?
osteoarthritis
What is the pathophysiology of OA?
cartilage changes including increased water content and altered collagen and proteoglycans that lead to cartilage destruction
Is OA more common in men or women?
Women
What are the x-ray changes associated with OA?
osteophytes, narrowed joint space, eburnation and subchondral cysts
What are common sites affected by OA?
DIPs and thumb carpometacarpal joints
How do you treat OA in DIPs?
Conservatively with rest, NSAIDs and steroid injections. If this fails, fuse joint in 10-20 degrees of flexion
What cells are involved in the formation of Dupuytren's contractures?
fibroblasts
What is the male:female ratio in Dupuytren's contractures?
10:1
What is the inheritance pattern of Dupuytren's contractures?
autosomal dominant with variable penetrance
What areas of the body are most commonly affected by Dupuytren's contractures?
palm, ring finger, small finger
What diseases are associated with Dupuytren's contractures?
alcoholism, diabetes, epilepsy, HIV, COPD
What are the 3 classic findings of Dupuytren's diasthesis?
knuckle pads, foot involvement (Ledderhose's disease), penis involvement (Peyronie's disease)
In Dupuytren's contractures, which band does NOT become diseased forming a cord?
Cleland's ligament (dorsal to the NV bundle)
What are the indications for surgical correction for Dupuytren's contractures?
Contracture causing maceration or hygeine difficulties, any PIP joint contracture, MCP joint contracture that significantly impairs ADLs
What are the surgical options for Dupuytren's contractures?
Subcutaneous fasciotomy (only for very sick or elderly patients), limied fasciectomy (resection of diseased tissue only), regional fasciectomy (resection of diseased tissue and a margin of healthy tissue), extensive fasciectomy (resection of diseased tissue and all potentially involved fascia), or radical fasciectomy
What skin incision is advocated in a palmar procedure to correct Dupuytren's contractures?
transverse incision in proximal palmar crease
What skin incision is advocated in a finger procedure to correct Dupuytren's contractures?
longitudinal incision broken up by Z-plasties over creases
What are the complications of surgical correction of Dupuytren's contractures?
hematoma, recurrence, nerve injury, vascular injury, stiffness, complex regional pain syndrome (fka reflex sympathetic dystrophy)
In Dupuytren's contractures, what are the best predictors of neurovascular bundle displacement?
PIP joint flexion contracture and interdigital nodule
What structures become the spiral band in Dupuytren's contractures?
pretendinuous band, spiral band, lateral sheet and Grayson's ligament (Plastic Surgeons Look Good)