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PassPMR - 07 Musculoskeletal Medicine > 4- Wrist & Hand > Flashcards

4- Wrist & Hand Flashcards

1
Q

Extensor Compartments of the Wrist 🔑🔑 MOCK

A

First compartment: APL, EPB

Second compartment: ECR-L, ECR-B

Third compartment: EPL

Fourth compartment: EDC, EIP

Fifth compartment: EDM

Sixth compartment: ECU

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2
Q

What are the components of the triangular fibrocartilage complex (TFCC)? 🔑🔑 Dr. Jamal

A

TFCC

  1. Dorsal Radioulnar Ligament
  2. Volar Radioulnar Ligament
  3. Ulnar Collateral Ligament
  4. Extensor Carpi Ulnaris
  5. Ulnocarpal Meniscus
  6. Ulnolunate Ligament
  7. Ulnotriquitrium Ligament
  8. Central Articular Disc

BLOOD SUPPLY

  1. Periphery is well vascularized
  2. Central portion is avascular

FUNCTION

  1. Primary stabilizer of distal radio-ulnar joint
  2. Load-bearing between carpal bones and ulna
  3. Support for the ulnar carpal ligament
  4. Transfer part of compression forces
    • Axially loading the wrist results in 18% of the load being born through the TFCC and the remaining 82% through the radiocarpal joint

MECHANISM OF INJURY

  1. Traumatic injury:
    • Fall on extended wrist with forearm pronation
    • Traction injury to ulnar side of wrist
  2. Degenerative injury:
    • Positive ulnar variance
    • Ulnocarpal impaction syndrome

EXAMINATION

  1. Tenderness to palpation in the hollow between the flexor carpi ulnaris tendon and the extensor carpi ulnaris tendon
  2. TFCC Compression Test Fig. 7.88 → ulnar deviation or radial deviation (TFCC tension)
  3. Testing the Ligaments of the TFCC Fig. 7.82
  4. Sitting Hands (Press) Test Fig. 7.61 → Chair lift off test
  5. Supination Lift Test Fig. 7.80
  6. Ulnar fovea sign (ulnar snuff box) test. Fig. 7.87 95% sensitivity and 87% specificity
  7. Ulnomeniscotriquetral Dorsal Glide Test Fig. 7.91

INVESTIGATION

  1. X-Ray PA to evaluate PA ulnar variance
  2. MRI
  3. Arthroscopy (Gold Standard, most accurate)

ER - POLICE - MIS

  1. Education & Risk Factor: Relative rest
  2. Protection & Orthosis: Short arm brace for 4 weeks
  3. Loading: ROM exercises after 1-2 weeks
  4. ICE & Modalities
  5. Medication: NSAIDs
  6. Injection: Steroid injection
  7. Surgery
    • Indication: Unstable injury, failure of conservative measurement after 3 months
    • Techniques: Arthroscopic repair, Ulnar shortening, Debridement

Braddom 6th Edition Chapter 35 UL Injuries pg723

https://www.orthobullets.com/hand/6047/tfcc-injury

Magee 7th Edition Chapter 7 Forearm, Wrist, and Hand

Dr. Ali Note

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3
Q

What structure Inserts on pisiform, hamate & 5th MC?

A

FCU tendon.

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4
Q

Differentiate between OA & RA. 🔑🔑 Etiology - Joint Involved - Deformities & PEx

A
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5
Q

Describe the treatment for first CMC arthritis.

A

CMC Joint Biomechanics

  • Pinch force generated at the thumb and index finger is greatly magnified at the CMC joint interface. In fact, 1 kg of pinch force translates to 12 kg of intra-articular pressure
  • Twisting activities also stress the CMC joint by causing a torque or twisting force on the joint.

💡 ER.POLICE.MS

  1. Education & Control Risk Factors
    1. Try to minimize fingertip-to-fingertip pinch activities
    2. Try to increase the size of the objects being pinched
    3. Enlarging the grip of tools or objects that are being gripped
    4. Use key holders and electric can openers to limit twisting torque
  2. Protection
    1. Daytime: Short opponens splint
    2. Nighttime: Long opponens splint
  3. ICE & Modalities
    1. Contrast baths, hot-water soaks, or paraffin baths
  4. Medications
    1. Oral NSAIDs
    2. Cortisone injections into the CMC joint
  5. Surgical
    1. Ligamentous reconstruction of the joint, 6 months of recovery, up to 70% of power

DeLisa 5th Edition Chapter 37 Hand pg941

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6
Q

Swan neck deformity & Boutonnière deformity.

Cause and Joint positions. 🔑🔑

A

Swan Neck:

Shortening and contracture of the intrinsic muscles of the hand

Flexion at the MCP joint - Hyperextension at the PIP joint - Flexion at the DIP joint

Boutonnière deformity:

Tearing of the extensor hood

Hyperextension at the MCP joint - Flexion at the PIP joint - Hyperextension of the DIP joint

Cuccurollo 4th Edition Chapter 4 MSK pg192

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7
Q

Mention 6 Extra articular manifestations of RA. 🔑🔑

A
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8
Q

De Quervain’s Tenosynovitis. Mechanism and explain your test. Tx.

A

💡 Women are affected 10 times more frequently than men.

Mechanism

Acute

  • Repetitive or direct trauma cause tenosynovitis of EPB and APL
  • Tendons in the first compartment of the wrist, run over the dorsal aspect of the radial styloid process
  • The function of these muscles is to position the thumb in extension and abduction in preparation for gripping and pinching.
  • Typical activities that may precipitate the condition include buffing, wringing, grinding, polishing, sanding, sawing, cutting, and screwdriver use
  • Seen in waitresses, hospital workers, garment workers, machine operators, and domestic cleaners

Chronic

  • Inflammation is absent, but degenerative thickening of the extensor retinaculum and synovial tendon sheath results in a mechanical stenosis within the first dorsal compartment, causing impingement of the two tendons

Presentation

  • Swelling over the radial styloid process with progression up into the radial aspect of the forearm or distally into the thumb
  • Pain increases with grasping, adduction of the thumb, or ulnar deviation of the wrist.

Finkelstein’s test

  • Flex the thumb into the palm of the hand with the fingers, making a fist over the thumb. Then passively ulnar deviate the wrist
  • Positive in RA patients & carpometacarpal osteoarthritis of the thumb as well.
  • Another useful clinical test is resisted thumb extension at the MCP with the wrist maintained in radial deviation

CR.POLICE.MS

  1. Control risk factor
    1. Activity modification (most important)
    2. Elimination of highly repetitive activities that include pinching or gripping
  2. Protection
    1. Thumb spica splint
  3. ICE & Modalities
    1. Ice application for 15 minutes every 6 hours
    2. NSAIDs.
  4. Medications
    1. Oral NSAIDs
    2. First dorsal compartment peritendinous corticosteroid injection
      • 81% of individuals undergoing injections described symptom relief at 6 weeks.
      • 58% remained asymptomatic, and 33% had complete reoccurrence.
      • One to three injections of hydrocortisone at 18-month follow-up
  5. Surgical
    1. Surgical decompression of the first dorsal compartment may be curative in approximately 90% of cases

💡 There has not been an outcome study on the use of modalities and exercise for this condition.

Cuccurollo 4th Edition Chapter 4 MSK pg193

DeLisa 5th Edition Chapter 36 & 37 Hand pg928 & pg942

Magee Orthopedic Physical Assessment 7th Edition

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9
Q

Spot diagnosis & Management

A

Ganglion Cyst

Structure filled with synovial fluid that arises from the synovial sheath of the joint space.

Management

  • Immobilization
  • Aspiration of the cyst (90% recurrence)
  • Surgical removal if needed (10% recurrence)

Cuccurollo 4th Edition Chapter 4 MSK pg193

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10
Q

Figure 1. Diagnosis, Seen in, Examination & Management. List 5 conditions associated with dupuytren’s contracture.

A

DUPUYTREN’S CONTRACTURE

Thickening and contraction of the palmar fascia due to fibrous proliferation

Flexion is commonly seen at the MCP joint involving the ring finger (fourth digit)

Seen in

  • DM, >40 years old, alcoholism, epileptics, and pulmonary tuberculosis (TB)

Presentation

  1. Painless nodules → tender as the disease progresses
  2. Finger flexion contracture

Conservative

  1. Physical therapy: stretching, massage, splinting
  2. Modalities—heating, ultrasound
  3. Corticosteroid or lidocaine injections and forceful extension
  4. Trypsin, chymotrypsin
  5. Collagenase injections

Surgical

  • Fasciotomy
  • Goal of surgery is to restore function, not to cure the disease
  • Reoccurrence rates range from 28% to 80%

Cuccurollo 4th Edition Chapter 4 MSK pg201

DeLisa 5th Edition Chapter 37 Hand pg947

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11
Q

Figure 2. Diagnosis, Seen in, Examination & Management.

A

STENOSING TENOSYNOVITIS: TRIGGER FINGER

  • Repetitive trauma causes inflammation of flexor tendon sheath of the digits.
  • Forming a nodule in the tendon → abnormal gliding through the A1 pulley system.
  • As the digit flexes, the nodule passes under the pulley system and gets caught on the narrow annular sheath and finger is locked in a flexed position.
  • Acute conditions demonstrate inflammatory changes in the region of the A-1 pulley.
  • Chronic conditions, no inflammatory changes are noted, but degenerative changes consistent with fibrocartilaginous proliferation of the A-1 pulley or tendon

Risk Factors

  • Repetitive trauma
  • DM, >40yo, RA, gout (trauma or inflammatory joint disease)
  • Serologic testing should be done to check for the presence of underlying conditions such as diabetes mellitus, hypertension, and inflammatory arthritis

Presentation

  • Painful locking with finger flexion and/or extension
  • Requiring passive assistance to obtain extension
  • Tender palpable nodule
  • Snapping or locking sensation with full flexion of the digit.
  • Usually worse in the morning and after repetitive gripping or pinching-type activities

CR.POLICE.MS

  1. Control Risk Factors
    1. Limiting activities requiring grasp, active flexion or repetitive stress
  2. Protection: Splinting for 3-6 weeks
  3. ICE & Modalities
    1. ultrasound
  4. Medications
    1. Oral NSAIDs
    2. Corticosteroid injection (77%-97% improvement with one to three injections)
  5. Surgery
    • Surgical release if conservative treatment fails

Cuccurollo 4th Edition Chapter 4 MSK pg202

DeLisa 5th Edition Chapter 37 Hand pg942-943

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12
Q

TFCC. Examination & List 4 functions 🔑🔑 Dr. Jamal

A

💡 A positive ulnar variance (longer ulna than radius at the level of the wrist) results in an increase in the load-bearing function of the TFCC.

TFCC

  1. Avascular central articular disc
  2. Vascular dorsal and palmar radioulnar ligaments

Function

  1. Primary stabilizer of distal radio-ulnar joint
  2. Transfer part of compression forces
    • Axially loading the wrist results in 18% of the load being born through the TFCC and the remaining 82% through the radiocarpal joint
  3. Load-bearing between carpal bones and ulna
  4. Support for the ulnar carpal ligament

Examination

  1. Tenderness to palpation in the hollow between the flexor carpi ulnaris tendon and the extensor carpi ulnaris tendon
  2. TFCC Compression Test
  3. TFCC Stress Test
  4. Sitting Hand Test
  5. Supination Lift Test

Surgical Referral

  • Ulnar shortening procedure should be considered along with surgical debridement of the TFCC

Braddom 6th Edition Chapter 35 UL Injuries pg723

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13
Q
A

Boxer fracture, Fracture neck of 5th MCP

PMR Secrets 3rd Edition Chapter 45 Hand & Wrist

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14
Q

Figure 2. Can’t flex tip of his finger. Diagnosis, Examine FDP & FDS & Management. How can you test the integrity of FDS & FDP ? 🔑🔑

A

JERSEY FINGER

Injury to the FDP tendon.

Mechanism

Forceful DIP extension while the FDP muscle is contracting can result in injury FDP tendon

+/- Avulsion fracture

Testing of the FDP

Flex the DIP while the PIP joint is held in extension.

Action of the FDS is eliminated when the PIP is maintained in extension.

Testing flexion of the FDS

Hold the DIP of the noninvolved digits in extension.

Then ask the patient to flex the unrestrained digit.

This maneuver isolates the FDS and eliminates action of the FDP

Management

Early orthopedic referral for surgical repair

Cuccurollo 4th Edition Chapter 4 MSK pg204

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15
Q

Figure 3. Unable to extend the tip of his finger. Diagnosis, Examination & Management.

A

MALLET FINGER

Sudden passive flexion of the DIP joint when the finger is extended

Causing a rupture of the extensor tendon

+/- Avulsion fracture of the distal phalanx

Examination

Flexed DIP joint that cannot be actively extended

Management

Stack splint of the DIP in extension for 6 to 8 weeks

Maintaining the DIP in extension at all times

Then, gentle active flexion with night splinting should be done for 2 to 4 weeks

Surgical Referral

  • Surgical repair reserved for poor healing
  • Avulsed fragment

Cuccurollo 4th Edition Chapter 4 MSK pg205

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16
Q

Patient with wrist fracture What is your Dx? Prescribe an orthoses.

A

Smith’s fracture

  • Fracture of the distal radius with volar displacement and angulation

Colles’ fracture

  • Fracture of the distal radius with with dorsal displacement and angulation
  • Associated with triangular fibrocartilag complex (TFCC) & scapholunate dissociation

Orthopedic referral for closed reduction.

Cuccurollo 4th Edition Chapter 4 MSK pg197

17
Q

What u doing next?

A

Galeazzi Fractures → Lateral wrist radiographs

Distal 1/3 radial shaft fracture with an associated distal radioulnar joint (DRUJ) injury.

Treatment is generally ORIF of the distal radius followed by assessing the stability of the DRUJ which may be warrant subsequent immobilization, DRUJ pinning or ORIF of the DRU

https://www.orthobullets.com/trauma/1029/galeazzi-fractures

18
Q

List 3 MSK complications in the hand of diabetes (diabetic).

A
  1. CTS (carpal tunnel syndrome).
  2. flexor tenosynovitis (trigger finger)
  3. dupuytrens contracture
  4. stiff hand syndrome
  5. diabetic sclerodactyly
  6. diabetic cheiroarthropathy

Ref: CLINICAL DIABETES•Volume 19, Number 3, 2001.

19
Q

List 3 MSK complications of the shoulders in diabetes.

A
  1. adhesive capsulitis
  2. calcific periarthritis
  3. reflex sympathetic dystrophy (CRPS)

Ref: CLINICAL DIABETES•Volume 19, Number 3, 2001.

20
Q

List 4 MSK complications of hypothyroidism

A

Summary, similar to Diabetes “hand & shoulder”:

  1. Carpal tunnel syndrome
  2. Stenosing tenosynovitis / trigger finger
  3. Dupytren’s contracture
  4. Adhesive capsulitis
  5. Myopathy

Systemic

  1. Arthralgias
  2. Myalgias
  3. Distal weakness
  4. Ataxia
  5. Myopathy

Clinical Endocrinology (2003) 59, 162– 167

21
Q

Mention the carpal bones arranged from radial to ulnar, proximal to distal sides 🔑🔑 EXAM 🟦

A

She looks too pretty, try to catch her

Scaphoid - Lunate - Triquetrum - Pisiform

Trapezium - Trapezoid - Capitate - Hamate

PassPMR - 07 Musculoskeletal Medicine (8 decks)

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