2.06 - Trauma and Orthopaedics - The Wrist and Hand Flashcards
Which nerve is affected in carpal tunnel syndrome?
Median nerve is compressed within the carpal tunnel of the wrist, due to a raised pressure within the compartment.
What are the risk factors for carpal tunnel syndrome?
- female gender
- increasing age
- pregnancy
- obesity
- previous injury to the wrist
What are the clinical features of carpal tunnel syndrome?
Throughout the median nerve sensory distribution, the patient will present with:
- pain
- numbness
- paraesthesia
In later stages of CTS, there may be weakness of thumb abduction and wasting of the thenar eminence, due to denervation atrophy of the thenar muscles.
Why is the palm often spared in carpal tunnel syndrome?
The palm is innervated by the palmar cutaneous branch of the median nerve, which branches proximal to the flexor retinaculum and therefore passes over the carpal tunnel.
What are the special tests that can be used to diagnose carpal tunnel syndrome?
Tinel’s test - positive if symptoms reproduced by percussing over the median nerve.
Phalen’s test - positive if symptoms reproduced by holding the wrist in full flexion for one minute.
What are some differentials for carpal tunnel syndrome?
- C6 radiculopathy
- pronator teres syndrome
- flexor carpi radialis tenosynovitis
How is carpal tunnel syndrome investigated?
Usually a clinical diagnosis, based upon history and examination findings.
In uncertain cases, nerve conduction studies may be useful to confirm median nerve damage.
What is the conservative management of carpal tunnel syndrome?
- wrist splint
- hand therapy
- corticosteroid injections into the carpal tunnel
What is the surgical management of carpal tunnel syndrome?
Carpal tunnel release surgery decompresses the carpal tunnel.
Involves dissecting the flexor retinaculum, in turn reducing pressure on the median nerve.
When is surgical treatment of carpal tunnel syndrome indicated?
Undetaken in a symptomatic patient, where previous conservative treatments have not been successful
What are the complications of carpal tunnel release surgery?
- recurrence
- persistent symptoms
- infection
- scar formation
- nerve damage
- trigger thumb
What are the complications of long-term untreated carpal tunnel syndrome?
Neurological impairment
What tissue in particular is affected by Dupuytren’s contracture?
Contraction of the longitudinal palmar fascia
Explain the pathophysiology of Dupuytren’s contracture.
Fibroplastic hyperplasia and altered collagen matrix of the longitudinal palmar fascia leads to a thickening and contraction of the fascia.
Contraction of the fascia pulls on the MCP and PIP joints, leading to a progressive flexion deformity in the fingers.
What are the risk factors for Dupuytren’s contracture?
- smoking
- alcoholic liver cirrhosis
- diabetes mellitus
- occupational exposures (e.g. use of vibrational tools)
What investigations can be used to diagnose Dupuytren’s contracture?
Diagnosis usually clinical, but can us USS for increased accuracy in applying intralesional injections.
Patients should ideally have routine bloods including LFTs and HbA1C to assess for associated risk factors.
What is the management of Dupuytren’s contractures?
Conservative measures:
1. Hand therapy, to keep the hand active with stretching exercises.
2. Injectable CCM
Surgical management:
1. Fasciectomy of diseased fascia
2. Finger amputation - rarely required
When is surgical management of Dupuytren’s contracture indicated?
- functional impairment
- MCP joint contracture >30°
- PIP contracture
- rapidly progressing disease
What is De Quervain’s tenosynovitis?
Inflammation in the tendons within the first extensor compartment of the wrist, resulting in wrist pain and swelling.
Compartment 1: extensor pollicis brevis and abductor pollicis longus.