Hand Fingertip Amputations, Dupuytren's, Vascular

Buerger disease

Acquired vasculitis in smokers, often bilateral

Stenosis, ectasis (corkscrew pattern)

Angiogram findings (2) with hypothenar hammer syndrome

Healing by secondary intention

Best method of reconstruction to preserve fingertip sensation

Toe-to-thumb transfer

Best reconstruction for thumb at MCPJ level

Calcinosis Raynaud phenomenon Esophageal dysmotility Sclerodactyly Telangiectasias

CREST syndrome

Extension deficit

Common complication after Moberg flap for thumb reconstruction

>30 mmHg or <30 mmHG difference between compartment pressure and DBP

Compartment pressure indicative of compartment syndrome

Crush injury Multi-level injury

Contraindications (2) to finger replantation

Unstable patient who can't tolerate prolonged operation Patient where amputation and prosthesis would provide better functional result

Contraindications (2) to immediate limb replantation

FDMA flap

Coverage for thumb with denuded tendon

I: 3 months, pain out of proportion, hyperesthesia, edema, hyperhidrosis. II: dystrophic; 3-9 months, pain, stiffness, altered blood flow, hair loss, decreased moisture, osteopenia. III: atrophic; 9-18 months, decreased pain, increased stiffness.

Describe 3 stages of CRPS

Hyponychium

Distal junction of skin and nail

Eponychium

Distal nail fold attached to surface of nail

Trephination

Drainage of subungual hematoma

Little, FDMA 1 year

Fingertip flaps (2) that are innervated and sensate. How long does cortical reorientation take?

First dorsal metacarpal artery flap involving branches of radial artery, superficial sensory branch radial nerve

Flap to provide sensate coverage of thumb. Arterial and nerve supply.

Amputations at proximal phalanx or more distal

For what thumb amputations is distraction osteogenesis useful?

Reverse radial forearm

Forearm flap with pedicle long enough to reach fingertip

3:1 male to female

Gender predominance for Buerger disease

9:1 male to female

Gender predominance for hypothenar hammer syndrome

Homodigital island flap

Good reconstructive option to maintain fingertip sensation

Equivalent

How do rates of replant survival and thrombosis change if vein grafts are used?

By positioning amputated nerve stumps well within remaining muscle and far from cutaneous closure

How does TMR improve prosthesis control?

Sterile matrix adds thin layer of cells to undersurface of nail

How does the nail remain adherent?

2 years 10-11 mm

How long does cortical reorientation take after FDMA flap reconstruction of thumb? What is the average static 2 point discrimination?

6 hours 30%

How soon does a high pressure paint gun injury need to go to the OR? What is the amputation rate?

10 cm

Ideal distal of forearm amputation from wrist to allow for adequate soft tissue coverage

Warm ischemia < 6 hours Cold ischemia < 10 - 12 hours If long ischemia time, perform arterial anastomosis all allow runoff prior to venous anastomoses

Ideal warm and cold ischemia times for limb replantation. What can you do if ischemia time is prolonged?

Volar oblique, as advancement would be inadequate

In what pattern of fingertip amputation is a volar V-Y advancement contraindicated?

Digital ulceration DBI < 0.7

Indications (2) for surgery with hypothenar hammer syndrome

Extended warm ischemia time > 8 hours Combined injury involving both major arteries and veins

Indications for prophylactic fasciotomies of forearm

MCPJ contracture > 30 degrees Any PIPJ contracture

Indications for surgery for Dupuytren contracture

Fracture of hook of hamate

Injury often seen in athletes who use rackets

No

Is innervation transferred in thenar or cross finger flaps?

No

Is reverse radial forearm flap sensate?

Perionychium

Lateral borders of nail

Medial plantar artery fasciocutaneous flap

Local flap for coverage of defects on forefoot/heel

Small finger FDP

Loss of this muscle results in significant loss of grip strength

Antigen antibody complexes activate complement system, causing massive capillary thrombosis, preventing vascularization of graft

Mechanism of action of hyperacute rejection

Myofibroblasts act on collagen bundles deposited by fibroblasts

Mechanism of formation of Dupuytren cords

2cm

Moberg advancement flap can cover thumb defect up to what size

Long finger

Most common fingertip injured

Non-adherence of nail Scarring of nail bed

Most common nail deformity after trauma. Most common cause of this.

Minor intrinsic hand weakness

Most common side effect of Botox A injection for Raynaud's

CRPS Stage II Post-menopausal women

Osteopenia is related to disuse and is a typical finding in which type of CRPS? What demographic is this more common in?

Repetitive blunt trauma to hypothenar eminence causes thrombosis of ulnar artery at Guyon canal. Emboli decrease flow, cause cold sensitivity, ischemic pain, rubor, ulcerations in small and ring fingers.

Pathophysiology of hypothenar hammer syndrome

Germinal matrix

Portion of nail responsible for 90% of new nail growth

Bones, tendons, arteries, nerves, veins Artery first if prolonged ischemia time

Preferred sequence of reconstruction for multiple digits. How might this change?

Takes ~3 months, averaging 0.1mm daily

Rate of nail growth

Does not affect epiphyseal growth Children adapt well to functional deficits Microvascular repair has high success rate

Reasons (3) for replantation in children

Cross finger flap with bone graft

Reconstruction for hook nail deformity

Toe-thumb transfer

Reconstruction for thumb amputation without possibility of replantation

Pollicization of index finger

Reconstruction for thumb avulsion with CMCJ disruption

Volar V-Y advancement

Reconstruction for transverse and dorsal oblique fingertip amputations

<1 mm: scar excision, nail bed advancement, primary closure. >1 mm: scar excision, adjacent finger graft, eponychial fold flap

Reconstruction of scarred nail bed (< 1mm vs > 1mm)

Amputation and avulsion. Replantation with vein grafting.

Roping injury to digit results in what combination of injury patterns? How would you reconstruct this?

Great toe wraparound flap

Sensate reconstruction for skin avulsion of distal thumb with intact neurovascular structures

5-10 cm

Shortest stump length distal to elbow to maintain native elbow motion when fitting prosthesis

Mild: elevation, cold compresses Severe: evaluation of compartment pressures w/ potential decompression

Treatment for IV extravasation with mild symptoms? Severe symptoms?

Graft from 1st or 2nd toe

Treatment for nail bed injury involving both sterile and germinal matrices

Excision and primary closure

Treatment for nail bed scar involving sterile matrix only

FDMA flap for sensate reconstruction

Treatment of large volar thumb soft tissue defect

Local wound care

Treatment of volar thumb soft tissue defect <1 cm

Moberg flap

Treatment of volar thumb soft tissue defect up to 2cm

Acute humoral

Type of rejection that occurs in 3-6 days and is mediated by immune complexes rapidly induced after graft exposure

Acute cellular

Type of rejection that occurs in 3-6 months, mediated by T cells activated against donor antigens, primarily in lymphoid tissue

Hyperacute

Type of rejection that occurs in minutes to hours due to preformed antibodies in recipient

Chronic

Type of rejection that occurs over years and is antibody and cell mediated

Botox A injection

Used to treat vasospastic disorders of digital vessels

Aeromonas infection Invade walls of blood vessels Ceftriaxone Produces beta-lactamase (penicillins and 1st generation cephalosporins ineffective)

What bacteria must be covered for prophylactically when using leech therapy? What capability does this bacteria have? What antibiotic is used to do this? Why this antibiotic?

Nail cell nuclei in germinal matrix stream distally, creating difference in light detection

What causes the lunula of the nail?

Volar soft tissue loss with nail bed folding over residual tip

What is a hook nail deformity?

Paradoxical extension of PIP w/ active flexion due to increased tension on lumbricals from FDP retraction. Treat with division of lumbrical.

What is a lumbrical plus deformity after amputation of finger? How is this treated?

Normal: 0.75 - 0.97 Inadequate perfusion: < 0.7 Tissue loss: < 0.5

What is a normal digital brachial index? What indicates inadequate perfusion? What indicates tissue loss?

Dupuytren's disease affecting pretendinous band, spiral band, lateral digital sheath, Grayson ligament. Displaces neurovascular bundle centrally.

What is a spiral cord? Where is the neurovascular cord displaced?

Non-vascularized bone graft covered with local pedicled flap

What is an 'on top plasty'?

Volar curvature of nail that occurs because of lack of bony support to sterile matrix, typically secondary to trauma

What is hook nail deformity?

Longitudinal nail split, often caused by adherence of nail fold dorsally and nail bed volarly if nail fold not stented open after trauma

What is synechiae? What can cause it?

None Rare 8 weeks post-procedure

What is the incidence of digital nerve rupture during cord injection with Xiaflex? Pulley and flexor tendon rupture? How long until surgical exploration is indicated?

Inhibition of Rho/Rho kinase activity, inhibition of substance P secretion and receptor sensitivity, decreasing activity of chronically up-regulated C-fiber nociceptors

What is the mechanism of action of Botox for treatment of Raynaud?

Skin Acute rejection (type II hypersensitivity) mediated by IgM, IgG

What is the most reactive component of a composite tissue allograft? What type or rejection is this and how is it mediated?

Repair of at least 2 dorsal veins

What is the only factor that influences digit survival in ring avulsion injury?

Neurovascular compression of subclavian vessels and brachial plexus

What is thoracic outlet syndrome?

Only in acute setting to evacuate hematoma

What is trephination of nail appropriate?

Biceps tendon transfer to ulna

What maneuver can decrease risk of flexion contracture at elbow in transradial amputation?

Release checkrein ligaments, then accessory collateral ligament

What should you do in PIPJ remains in flexion after Dupuytren's fasciectomies?

Median nerve Deep to bicipital aponeurosis

What structure can be injured by brachial artery catheterization? Where does this structure separate from the brachial artery?

Sterile matrix

What structure is shortened in hook nail deformity?

1.2 - 1.4mm proximal to germinal matrix

Where do extensor tendons of fingers insert?

Reverse cross finger flap uses only subcutaneous tissue from donor, with FTSG placed over recipient site

Where is the skin graft placed in a reverse cross finger flap?

Limited fasciectomy

Which treatment for Dupuytren's contracture provides the greatest degree of initial correction and longest period prior to recurrence, but also the highest cost?