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nerve compression

Arcade of Struthers
Ligament of Struthers
Froshe = Radial
Archade of Struthers = Median
Ligament of Struthers = Ulnar
Osborne = Ulnar
Collar button Abcess via ?
lumbrical canal or
palmar fascia
juvenile rheumatoid arthritis

wrist = flexion

carpo/metacarpal = ulnar dev.

loss of flexion IP & MPjoints

radial deviation of MP
Subungual melanoma

Upper extremity embryologic development tissue
Apical Ectrodermal Ridge
SLAC wrist
scapholunate advanced collapse

Rx = four corner arthrodesis
thumb hypoplasia
I small

II small, unstable,thenar cone decrease or absent

III short, web space contracture, absent thenar cone, global instability

IV absent
small finger

not progressive after puberty

mild = splint
severe = surgery

age for surgery
sex distribution
surgery = 12 - 18 mo.

inherited = 10 - 40%

Scaphoid fracture healing


displaced 1 mm

best rx
nondisplaced = 90% unite (10-14 wks)
displaced 1 mm = 50%
rx = vascularized bone graft
rx of chronic paranechia
epinechial marsupialization
rheumatoid swan neck deformity

tight intrisics
rx of sagital band rupture
splint 2 weeks
Moberg transfer for thumb pinch
FDP tenodesis
Reiters Syndrome
(psoriatic arthritis)
oncomysosis rx
trigger finger release in

rheumatoid arthritis
further agrivates ulnar drift
structures causing failure of reduction of mp joint dislocation
flxr tendon
volar plate
"clench fist"

sensory fiber function

pain (burn)
moving 2pd
static 2pd
vib = pacinian
burn = C fibers
sharp = A fibers
mov 2pd = meisner's
stat 2pd = merkel cell
present at birth
partial or complete absence of fingers
glomus tumor
recur = 20%
multiple = 25%
C5-6 tetraplegia - correction of forearm suppination
redirect biceps through interosseous membrane
bone scan result
normal = observation
abnormal = amputate pip and vascular tissue cover
Rx of rupture ring and small finger extensors in rheumatoid arthritis
Darrach procedure
Moberg flap

maximun defect size
2 x 2 cm
structure preventing reduction of volar pip dislocation
condyles of prox phalynx pass through the ext tendon
genetic transmission of congenital amputation
Rx camptodactyly
release abnormal lumbrical
delta phalynx
longitudinally bracketed epiphysis
brachioradialis flap
antecubital fossa
recurrent radial artery
blood supply for osteocutaneous radial forearm flap
fasciocutaneous perforators from radial artery
bet. brachiorad. and fcr
Rx electrical burn
0.9% NaCl
how long post injury can a boutinairre still be treated by splinting
6 wks
nerve repair

first sensory return
nerve growth = 1mm/day
Rx osteogenic sarcoma
radical exc.
radio Rx
chemo Rx
Rx frostbite
anti inflammitory Rx
decreases thrombuxane B2
decreases protoglandi F
margin of excision merkel cell ca
3 cm
type III dislocation pip
communited fracture

Rx = volar plate arthroplasty`
etiol of mp flxn in dupuytren.s
pretendinous cord
first carpal bone to ossify
most common cause of pip contracture in dupuytren's
central cord
lobster claw hand - inheritence
autosomal domninent
dorsal dislocation mp joint
reduction technique
wrist flexion and pressure on proximal phalynx (not distraction)
structures blocking reduction of mp dislocation
lumbrical, fdp, volar plate
giant cell tumor of bone
multinucleated giant cells
test for radial tunnel syndrome
selective local anesthetic
most common nerve palsy in brachial touniquet
timing of tendon transfer in radial palsy
no return in 6 months
volkman's (mild)
most com. nerve involved
most com. muscle

fdp and fpl
radial forearm flap - bone
10 -12 cm
brachial plexus birth injury
prognosis based on time to recovery of deltoid and biceps function
2 months = complete recovery
6 months = no recovery
posterior interosseous flap
what muscle taken when incorporating bone
lateral arm flap
sensory nerve
posterior brachial cutaneous nerve
lateral arm flap
bone length
10 cm
lateral arm flap
posterior radial collateral
spastic cerebral palsy, clenched fist with poor sensability and palm masseration (2pd 10mm)
transfer fds to fdp

lengthens the flexors
stab wound injuring ant tib artery,
most likely area aneathesia
first webspace

deep peroneal nerve
innervation dorsum of foot
superficial peroneal nerve
innervation lateral foot
sural nerve
innervation medial foot
saphneous nerve
HFl burn
copious irrigation water or saline
topical or injected Calcium Gluconate
mid palmar space
flx tendons, metacarpals,interosseous fascia, septum from 3rd mc to fdp sheath and hypothenar em.
volar dislocation of middle phalynx

what structure is interposed in the joint
extensor tendon
artery for toe to hand transfer
1st dorsal metatarsal artery from the dorsalis pedis
most common organism in hand infection
staph aureus
lumbrical plus deformity
paradoxal extension of the pip joint on attempted flexion

(occurs with dip amputations and with excessively long tendon grafts)

loss of flexion less that 30 degrees
kanavel's signs
fusiform swelling
flex posture
pain on passive extension
pain over the digital theca
devascularized long finger following repalntation

best functional result
ray amputation
Rx for venous congested reverse radial forearm flap
anastomsis of outflow vein
most important factor in success of replantation
mechanism of injury
split nail deformity
full thickness nail grafting from the toe
dorsal dislocation of the mp joint

structure preventing reduction

volar plate

flexor digitorum profundus
posterior interosseous flap with vascularized bone

which muscle supplies the bone
incomplete simple syndactyly

age of repair
12 - 18 months
pincer or trumpet nail deformity

lateral elevation of nail and dermal grafting
dupuytren's diathesis
knuckle pads
plantar fascial nodules

more agressive, earlier onset, more often bilateral and more often radial
compartment syndrome (hand intrinsics)

two dorsal incisions over the index and ring m/c

hypothenar and thenar cone decompression from mid axial incicions

no palmar incisions
electrical burn of hand and forearm
requires fasciotomy

(not escarotomy alone)
congenital constricting bands of extremities

excision of the bands and z-plasty
painful nail plate and sensativity to cold
glomus tumor
radial palsy

tendon transfer
p.t. - ecrb

fcu - edc

pl - epl
painful ulcerations, calcium deposits in soft tissue,
ischemia, flexion contractures, ip joint erosion, entrapment neuroapathy
crest syndrome
esophageal envolvemsnt
pain in hand with activity,
paresthesia involving palm
" " radial
pronator syndrome
dorsal dislocation pip joint

irreducible = fdp or volar

open rx = partial division of
A3 pulley
burn hand

pip joint active flexion lag with mp flexion intact
read question carefully

if the question reads
"burn hand" and not fingers then rx = tendon release central slip
traumatic amputation of all fingers

order of repair
structure by structure beginning with bone

(not finger by finger)
inablity to flex the dip joint of index finger with normal sensability
anterior interosseous syndrome

(pronator syndrome = sensability changes)
digit migration

at which level
metacarpal base

(more cancellous bone for union)
ray amputation of the index finger
20% loss of key pinch and
power grip
50% loss of suppiantion and
pronation strength
better cosmesis
dorsal intercalated segment instability

rx = operative repair (early)
fracture scaphoid with displacement

orif (herbert scew or compression screw)
circumflex scapular artery

triangular space
long head triceps

teres major

teres minor
nondisplaced scaphoid fracture

thumb spica for ____ weeks
10 - 14
inability to flex the pip joint following dip amputation
lumbrical plus deformity

rx = release of the lumbrical
rheumatoid arthritis

flexor tendon most likely to rupture
pain and crepitus 4 cm proximal to dorsal wrist crease after strenous activity
intersection syndrome
(between 1st and 2nd cmpt)
intersection syndrome

injection cortisone and splint

surgery = release 2nd dor cmpt
+ synovectomy when
conservative rx fails
12 cm tibia defect
contra lateral free fibular flap

(20 cm available)
sudden loss of flexion 5 weeks after repair

explore and repeat repair
thumb volar pad amputation

2x2 cm
moberg vlap
most sensative of kanavel's signs
passive extension
venous congestion of replant

immediate Rx
remove dressings
pan-trapezial arthritis

failing medical rx
trapeziectomy and tendon interposition
delayed infection of tibial fracture

initial rx
debride bone
congenital trigger thumb

age dx
rx = tenovaginotomy A1

age = usually not recognized till 6 mo.

30% resolve by age 3
first dorsal metacarpal flap

artery location
1st dor met art located within fascia of 1st dorsal interosseous
game keeper's thumb

structure interposing between ulnar collateral ligament and proximal phalynx
adductor pollicus
effort induced carpal tunnel syndrome

fanconi syndrome
radial club hand

autosomal dom

thumb hypoplasia
VATER syndrome
v = vertebral anom
a = anal anom
t = trach anom
e = esoph anom
r = renal anom
dupuytren's contracture

pip joint
natatory ligament = NOT involved
thumb-in-palm deformity
spasticity adductor, fpl
skin contracture
dec mobility mp joint

NOT flaccidity ext mech.
finger tip amp with tendon exposed

thenar vs cross finger
(inj may preclude one)
fixed flxn deformity at ip joint thumb in 4 y.o.
dongenital trigger

release A1
absolute contranindication to replantation
life threatening condition

all others are relative contrindications
complete ring finger avulsion

complete amputation
contrast extravasation associated with compartment syndrome
volumes greated than 100 cc

(dx - pain on extension confirm with compartment pressures)
football tackle with immediate loss of dip flsx

zone of injury
zone I
surgical release of pip with resultant finger tip necrosis

stretching of dig arteries

(answer to the question but not in real life, would not happen with intact dorsal skin)

rx with collagenase
relieves mp contracture

not pip contracture
tibial defects
prox 1/3 = gastrocnemius

mid 1/3 = soleus
herpetic whitlow

dry dressings

(said that topical acyclovir is of limited benefit, don't know why they don't mention systemic acyclovir)
dupuytren's spiral cord = spiral band +
grason's ligament
terminal branch of posterior interosseous nerve

passes beneath
thumb defect 2x3 cm
kite flap

(moberg limited to 1.5 cm)
type IIIb hypoplastic thumb

ablation and index migration
wassel type IV

muscle transfer
ablation of radial digit requires transfer of APB
C5 tetraplegia

most imp muscle reconstructive function
elbow extension

(ability of patient to transfer)
a-v malformation

when excising do so widely

"local" excision = high recurrence
nonsmoker with ulnar digit ischemia
ulnar hammer syndrome

(buerger's(thromoangiitis obliterans) usually in smokers)
ulnar nerve elbow

structure causing compression
osborne's ligament
infection index finger drains to which space
thenar space
painful digit ischemia (reynaud's or scleroderma) failed medical rx =
conservative ammputation
most definative test of osteomylitis
bone biopsy and culture
ulnar collat lig instability mp thumb

structure interposing between lig and insertion
adductor pol
crush injury arm with pain on passive finger extension
tibial defect - 9 cm

free fibular flap

(6 cm or less usually traditional bone graft)
advantage of wrist disarticulation vs forearm amp.
preserve pronation/suppination
stellate laceration sterile matrix

repair matrix and replace nail plate

(test answer - not in my patients)
arthrodesis angles pip joints
index = 40
long = 45
ring = 50
small = 55
arthrodesis angles mp joints
thumb= 15
index = 25
long = 30
ring = 35
small = 40
medial antebrachial cutaneous nerve graft

located next to
basilic vein
compartment syndrome hand intrinsics

minimum # incisions

thenar, hypothenar, two dorsal
if replanting complete ring avulsion

best chance for success
use ulnar dig a. from long finger
ray amp ring finger

structure to suture to close the gap
deep intermetacarpal ligament
limited pronation/suppination wrist in rheumatoid arthritis


(ulnar head resection)
neonate complete absence thumb
assoc with hematopoetic disorders
+spinal,cardiovasc,renal,gi,trisomy18,apert, carpenter
basilar thumb joint arthritis
not assoc. with rupture epl
extremity amputation and nerve repairs
when possibel shorten the extremity to perform primary nerve repair
flexor tendon repair strength related to
number of strands crossing the repair
six strand flx t. repair

post op management
best = early active motion

(test answer)
ulnar nerve at wrist

motor fasicle located
ulnar and dorsal
3 y.o. with finger tip amp.

best rx
replant the amp segment as composite graft
(when available)
mallet finger with >30% joint surface

closed reduction with k wire

orif also acceptable
limited flexion of adjacent digits post advancement repair of profundus tendon
quadragia effect
TAM (total active motion) of digits =
total flexion - extension lag
glomus tumor

simple excsion
congenital band amputation of all fingers

toe transfer
moberg flap

both digital arteries

both digital nerves
following amputation of distal phalynx
paradoxical extension of pip joint on attemnpted flexion
lumbrical plus deformity
exposed dialysis gortex in antecubital fossa

best flap artery
radial recurrent

(brachioradialis flap)
arm amputaion at humerus level

1st rx
arterial shunting
(answer for major limb amputations, otherwise bone fixation is first)
dupuytren's nodule

delta phalynx

also called
longitudinally bracketed epiphysis
severe pain, swelling, and discoloration 1 month post minor injury to hand =
reflex sympathetic dystrophy
most effective method of clearing bone adherent bacteria in open wound
surgical soap
pain over mobile wad and pain with resisted long finger extension and suppination =
radial tunnel syndrome
pacinian corpuscles

associated with what other anomalies
usually none

(usually an isolated finding)
acute closed boutonnier deformity

how long delay and still splint
10-21 days
pronator syndrome

sensability change
fingers + palm
delta phalynx

Volkman's contracture

most common finding
fibrosis of flexor muscles
moberg flap
1-1.5 cm
healing wound foot

pressures and O2 levels
ankle and great toe pressure

transcutaneous O2 > 30 torr
trans-scaphoid perilunate dislocation

carpal tunnel release

relocate lunate

repair volar raciocarpal lig.
sensation return post graft or flap
ftsg > stsg
rice bodies in tenosynovitis
acid fast organism
finger tip amputation with volar to dorsal angulation

atasoy klinert flap

(test answer)
dupuytren's contracture

indication for surgery
mp =/>30 degrees

pip any contracture (15 deg.)
volar wrist ganglion

excision = lowest recurrence rate
touniquet time > 2 hours
release for 20 minutes then re-inflate (5min / 30 min of
dorsal finger injury with loss of epitenon

flap coverage - reverse radial forearm

(test answer)
exposed nerve

flap cover
normal scapholunate angle
30-60 degrees
ulnar hammer syndrome

resection and vein graft
holt-oram syndrome
cardiac plus upper extremity syndrome anomalies
chronic schapholunate dissoc. with pain and radioschaphoid arthritis

prox. row carpectomy

implant vs tendon interposition
no diff in pain relief

do diff in post op strength
valium and pregency
risk to the fetus exists
compartment syndrome in the hand
pain on passive adduction and abduction of fingers
absent epl function

ext ind proprius transfer
1:1000 of 1% providone-iodine
non toxic and effective antimicrobial
amputation and warm ischemia
with muscle < 8 hrs.

without muscle 10 - 12 hrs.
comminuted frx pip joint

acute Rx
dynamic traction
traumatic nail plate deformity

sterile matrix graft

(test answer)
electrical burn upper extremity

rsd (crps - complex regional pain syndrome)

Dx test
three phase bone scan

(diffuse periarticular activity)
palmar numbness and carpal tunnel syndrome
no correlation

(palmar sensory cutaneous nerve enters the palm before the carpal tunnel)
which flexor tendo zone laceration has the best prognosis
Zone 5
thumb mp joint ulnar collateral ligament fracture
thumb mp joint ulnar collateral ligament fracture

what structure interposes between the fragments
adductor apponeurosis
thumb mp joint ulnar collateral ligament fracture

indications for repair
30 degrees of radial deviation instability
rheumatoid arthritis in all upper extremity joints

sequence of repair
proximal to distal

elbow-wrist-mp joints
rapid onset of psoriatic arthritis or reiter's syndrome

nail pitting, pain, stiffness,and swelling joints
subungual melanoma with mri suggesting possible extension along nv pedicle
interphalyngeal amputation

(ignore mri with initial rx)
fixed pip joint contracture

they want capsulectomy

(does not work, continue p.t. for a long, long, long time)
diabetic foot amputations

ankle-brachial indices for wound healing
0.70 or greater is acceptable for expected wound healing
congenital band syndrome with normal thumb and absent fingers
toe to hand transfer
widened scapholunate joint space =
scapholunate dissociation pattern or disi (dorsal intercolated segment instability)
irreducible volar pip dislocation
repair of lateral band and central slip of the extensor mechanism
absent (weak) extension of fingers and thumb with sensory deficiet =
posterior interosseous syndrome
pip joint contracture without trauma
ischemic fingers
if occluded radial or ulnar artery = bypass
total absence of radius

centralization of the ulna

(dx = radial club hand)
oblique fracture with comminution proximal phalynx thumb
type of fixation
lag screw and plate
the most important prerequisite for success of tendon transfers
full supple passive motion of the joints
nail bed (sterile matrix) injuries

test answer = remove nail plate and repair
(not my answer)
exposed achilles tendon repair
(soft tissue loss)

free flap
circumferential burn of extremity with vascular compromise

test for intrinsic tightness

(bunnell test)
extend mp joint and have patient attempt flexion of pip joint
moberg procedure for tetraplegia
thumb for adduction
tenodesis fpl to radius (plus release of annular ligaments)
tenodesis epl to radius
arthrodesis ip joint
% of people with a palmaris longus
71 - 85%
brachial-ankle index indicating ischemia
0.7 or less

(look out for this because would need bypass before ftt)
wassel type VII deformity
radial member of duplicated thumb is triphalyngeal
wassel deformities

for the test almost always will be presented with an ulnar dominent duplicate
the radial member is removed and the radial side of the remaining member is reconstructed (collateral lig., abductor tendon etc.)
distal phalynx mass with nail grooving
mucous cyst

(nail grooving resolves with removal of cyst)
SLAC wrist

Scapho Lunate Advanced Collapse

schaphoidectomy plus "four corner" arthrodesis
tendon transfers

if you do not recognize the choices
look at what will be "given up" with each transfer and eliminate the ones that would be inappropriate sacrifices
ring avulsions
incomplete should attempt salvage

complete = amputation (poss. attempt in the very young)
most appropriate nerve graft for digital nerve
test answer = posterior interosseous

(some would use the sural)
pain on resisted suppination

radial tunnel syndrome
chronic paranechia

first step =

"close association between chronic paranehia and scc)
exposed tendon or joint

flap cover (if large ftt. this is better than thick)
pain relief in severe rheumatoid arthritis wrist
white phosphorus burns
Rx = water lavage

copper sulfate used to identify areas of residual phosphorus
phenol burns
topical glycerol, propyleneor polyethylene glycol
smooth walled lytic lesion in phylanx
most common cause of pathologic fractures age 10 - 30 yrs
reynaud's - which is more effective

cervical sympathectomy or periarterial sympathectomy
periarterial sympathectomy
one of the relative "contraindications" to replantation
single digit proximal to fds insertion
radial aplasia or hypoplasia

need to evaluate for
is associated with several syndromes TAR (thrombocutopenia-absent radius) and Fanconi anemia

most common complication of surgery
recurrence of cord

(reported as 20-25%)
profundus distal phalynx fracture avulsion

avulsion of sterile matrix

great toe sterile matrix graft

(test answer)

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