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Trauma + Orthopaedics > 2: Joint Disorders Of The Wrist > Flashcards

2: Joint Disorders Of The Wrist Flashcards

1
Q

What is the commonest cause of nocturnal wrist pain

A

Carpal tunnel syndrome

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2
Q

What is carpal tunnel syndrome

A

Compression of the median nerve as it passes through the carpal tunnel (under flexor retinaculum)

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3
Q

What are 8 risk factors of carpal tunnel syndrome

A
  • Obesity
  • Hypothyroidism
  • Rheumatoid arthritis
  • Osteoarthritis
  • Repeated extension and flexion of the wrist
  • Previous distal radial fracture
  • Pregnancy (62%)
  • Diabetes
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4
Q

What type of symptoms will mild-moderate carpal tunnel syndrome present with

A

Only sensory symptoms

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5
Q

What are the sensory symptoms of carpal tunnel syndrome

A
  • Parasthesia of the thenar eminence, thumb, index, middle and medial-half of the ring finger
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6
Q

What symptoms will moderate-severe carpal tunnel syndrome present with

A

Motor and sensory

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7
Q

What are the MOTOR symptoms of carpal tunnel syndrome

A

Reduced strength in pincer grip - often complain of dropping objects

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8
Q

What is a very rare late sign of carpal tunnel syndrome

A

Wasting of the thenar eminence and reduced thumb opposition

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9
Q

What is hand of benediction and when is it seen

A

Inability to flex the thumb, index and middle finger. It is seen in injury of the median nerve higher up (NOT in carpal tunnel syndrome)

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10
Q

What is hand of benediction also referred to as

A

Pope’s blessing sign

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11
Q

What type of injury may cause hand of benediction

A

Supracondylar humeral fracture

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12
Q

When is an ulna claw seen

A

When patient tries to extend all their fingers (un-make a fist)

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13
Q

When is pope blessing sign seen

A

When patient tries to flex their fingers and make a fist

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14
Q

What are two signs seen in carpal tunnel syndrome

A

Tinel’s sign

Phalen’s sign

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15
Q

What is the carpal tunnel

A

Flexor retinaculum and associated carpal bones

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16
Q

What does the carpal tunnel contain

A

Flexor tendons and medial.N

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17
Q

Explain the pathophysiology of carpal tunnel syndrome

A

Any condition increasing pressure in the carpal tunnel can cause compression which impairs blood flow to the median nerve leading to an inflammatory reaction, oedema, hypoxia and degeneration

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18
Q

What is main investigation of carpal tunnel syndrome

A

Electromyography (EMG)

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19
Q

What 5 other investigations may be performed in carpal tunnel syndrome and why

A
  1. TFTs - increased risk in hypothyroidism
  2. Pregnancy test
  3. Fasting blood glucose - diabetes
  4. X-ray - OA
  5. anti-CCP - RA
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20
Q

How is mild-moderate carpal tunnel syndrome managed

A

Conservatively:

  • Night splint
  • Rest
  • Analgesia
  • Corticosteroid injections
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21
Q

How is moderate-severe carpal tunnel syndrome treated

A

Open or endoscopic release of transverse carpal ligament

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22
Q

What is a wrist ganglion

A
  • Non-cancerous soft tissue swelling along joint capsule or tendon sheath.
  • Benign lumps that arise from degeneration of joint capsule or tendon sheath and subsequently become filled with fluid
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23
Q

In which gender are wrist ganglions more common

A

Female

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24
Q

What age is peak incidence of wrist ganglions

A

20-40y

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25
Q

What are 3 RF’s for wrist ganglions

A
  • OA
  • Previous injury to the joint or tendon
  • Female
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26
Q

Why does OA increase risk of ganglions

A

Increases synovial fluid production which can then leak from the joint capsule or tendon sheath

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27
Q

What is the most common site for wrist ganglions to occur

A

dorsum of the wrist

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28
Q

What % of ganglions occur at the dorsum of the wrist

A

60-70%

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29
Q

How do ganglions present clinically

A
  • Painless, smooth spherical mass
  • Can appear suddenly or gradually
  • May appear and then subside
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30
Q

On examination, how may wrist ganglions appear

A
  • Transillumable

- Mobile

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31
Q

What may ganglions cause if placing pressure on nerves

A

Parasthesia or motor weakness

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32
Q

Give 3 differentials for wrist ganglions

A
  • Lipoma
  • Sarcoma
  • Tenosynovitis
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33
Q

How is tenosynovitis differentiated from a wrist ganglion

A

Swelling along the entirety of the tendon sheath

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34
Q

How is giant cell tumour differentiated from wrist ganglion

A
  • Not transillumable
  • Solid mass
  • Less mobile
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35
Q

How is a lipoma differentiated from a wrist ganglion

A
  • Not spherical or smooth

- Not transillumable

36
Q

How is a wrist ganglion diagnosed

A

Clinically

37
Q

Why may an x-ray be ordered for a wrist ganglion

A

To exclude osteoarthritis of the scaphotrapezotrapezoid joint or sarcoma

38
Q

Why may an US or MRI be ordered

A

To assess depth, size and shape of the ganglion

39
Q

What is the management of a non-painful non-limiting wrist ganglion

A

Active monitoring

40
Q

If a wrist ganglion is painful or limits movement what may be done

A

Aspiration

41
Q

What is the problem with aspirating a ganglion

A
  • Infection risk

- Often recurrs

42
Q

What other intervention may be offered for a painful, limiting wrist ganglion

A

Cyst excision

43
Q

What are the indications for cyst excision

A

Recurrence following aspiration and still symptomatic

44
Q

What is DeQuervain’s Tenosynovitis

A

thickening of the abductor polices Longus (APL) and extensor polices brevis (EPB) tendon due to myxoid degeneration

45
Q

What tendons are thickened in DeQuervain’s Tenosynovitis

A
  • Extensor polices brevis (EPB)

- Abductor polices longus (APL)

46
Q

Which gender is DeQuervain’s Tenosynovitis more common

47
Q

Which age group is DeQuervain’s Tenosynovitis more common

48
Q

What causes DeQuervain’s Tenosynovitis

A
  • Repetitive abduction and extension of the thumb

- Rheumatoid arthritis

49
Q

How will DeQuervain’s tenosynovitis present

A
  • Pain over radial aspect of the wrist. Exacerbated by gripping objects
  • Swelling at the dorsum of the thumb
50
Q

What is a stereotypical presentation of DeQuervain’s tenosynovitis

A

Pregnant women develops pain and welling over the thumb

51
Q

What sign is positive in DeQuervain’s tenosynovitis

A

Finklesteins sign

52
Q

What is finklestein sign

A

Pain on gripping the thumb to the palm of the same hand with passive ulna deviation

53
Q

Describe the pathophysiology of De Quervain’s tenosynovitis

A

There is thickening of the first extensor compartment which contains the APL and EPB tendons

54
Q

How is DeQuervain’s tenosynovitis diagnosed

A

Clinically

55
Q

How is DeQuervain’s tenosynovitis managed

A
  1. Conservatively. With analgesia (NSAIDs), thumb splinting (SICA) and corticosteroid injections
  2. Surgical release - if pregnant
56
Q

What is dupuytrens contracture

A

painless thickening of the palmar fascia

57
Q

In which gender is dupuytren’s contracture more prevalent

58
Q

What % of dupuytrens contracture occurs in male’s

59
Q

In which ethnic origin is dupuytrens contracture more common

A

scandinavian

60
Q

What is the pathophysiology of risk factors for dupuytren’s contracture

A

all risk factors cause ischemia of the palmar fascia increasing the risk of injury and thickening

61
Q

What are 5 risk factors for dupuytren’s contracture

A
  • Liver cirrhosis
  • Alcohol abuse
  • Diabetes
  • Smoking
  • Recurrent trauma (occupation)
62
Q

Why is dupuytren’s contracture looked for in an abdominal examination

A

As it can indicate liver cirrhosis

63
Q

Which fingers are most commonly affected in dupuytren’s contracture

A

4th and 5th fingers

64
Q

What is the earliest sign of dupuytrens contracture

A

Skin puckering by the flexure crease

65
Q

What are 3 other signs of dupuytren’s contracture

A
  1. Palmar nodules
  2. Palmar cords
  3. Flexion contracture
66
Q

What are palmar nodules

A

Formation of nodules adjacent to the distal palmar crease

67
Q

What are planar cords

A

Formation of cords adjacent to the nodules

68
Q

What is a flexure contracture

A

Contracture at MCPs and PIPS

69
Q

What is the problem with dupuytren’s contracture

A

Can interfere with function

70
Q

Explain the pathophysiology of dupuytren’s contracture

A
  • Injury to the palmar fascia triggers myofibroblast proliferation causing thickening and formation of nodules
  • Nodules adhere to overlying dermis causing puckering
  • Nodules progress to cords which form flexion contractures
71
Q

How can dupuytren’s contracture be diagnosed

A

Clinically

72
Q

What is first-line management of dupuytrens contracture

A

Conservative

  • Physiotherapy
  • Splinting
  • Corticosteroid injections
73
Q

When is surgery indicated for dupuytrens contracture

A

Functional disability secondary to contracture

74
Q

What does surgery for dupuytren’s contracture entail

A

Manipulation under anaesthesia

75
Q

What is another term from trigger finger

A

Stenosing tenosynovitis

76
Q

What is trigger finger

A

Swelling and thickening of the flexor finger tendons with associated stenosis of the A1 pulley

77
Q

In which gender is trigger finger more prevalent

A

Females (6:1)

78
Q

What is the peak incidence of trigger finger

79
Q

What are two risk factors for stenosing tenosynovitis

A

Diabetes

Rheumatoid arthritis

80
Q

What is the clinical presentation of trigger finger

A
  • Painful locking of the finger in a flexed position. On extension it will suddenly release to give a ‘popping’ sensation
  • Finger is commonly found flexed over the palm and needs physically straightening
81
Q

Which fingers are most commonly affected in stenosing tenosynovitis

A

Thumb
Middle
Ring

82
Q

How may trigger finger be identified on examination

A

Palpable nodules over MCP

83
Q

Explain the pathophysiology of trigger finger

A
  • Swelling of tendon sheath proximal to A1 pulley prevents tendon gliding and ‘catches’ it to cause locking in flexion
  • As extension occurs, the nodule moves with the flexor tendon but becomes jammed on the pulley and has to be flicked straight causing ‘triggering’
84
Q

What is the 1st line management of trigger finger

A

Conservative:

  • Splinting
  • NSAID
85
Q

What is second-line management of trigger finger

A

Surgical release of A1 pulley

86
Q

what structure is most likely damaged in scaphoid fracture

A

dorsal carpal arch of the radial artery

Trauma + Orthopaedics (11 decks)

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