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TRAUMA & ORTHO > 7: Hand and Wrist > Flashcards

7: Hand and Wrist Flashcards

1
Q

flexion and extension of thumb

A

flexion: can flex at both the IPJ and MCPJ/ when both joints are flexed, thumb bends across the palm
extension: return flexed thumb to anatomical position

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2
Q

radial abduction

A

continuation of extension beyond the anatomical position in the same plane as the palm (coronal plane)

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3
Q

opposition

A

rotatory movement of the thumb over the palm - it enables the thumb to touch the tips of the fingers

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4
Q

palmar adduction/abduction

A
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5
Q

circumduction

A
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6
Q

what is the carpal tunnel

A

narrow passageway on the anterior (volar or palmar) surface of the wrist that serves as an entrance to the palm for numerous tendons and median nerve

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7
Q

what are the borders of the carpal tunnel

A

deep border: comprised of the carpal bones which form a concavity
superficial border: flexor retinaculum aka transverse carpal ligament

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8
Q

what are the attachments of the flexor retinaculum

A

radial (lateral): scaphoid, trapezium
ulnar (medial) : hook of hamate, pisiform

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9
Q

what structures pass through the carpal tunnel

A
  • flexor pollicis longus tendon
  • flexor digitorum superficialis tendons x4
  • flexor digitorum profundus tendons x4
  • median nerve
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10
Q

where is the palmar cutaneous branch of the median nerve given off

A

proximal to the carpal tunnel
- clinically important in carpal tunnel syndrome as when the median nerve becomes compressed, sensation to the palm is unaffected

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11
Q

what is guyon’s canal

aka ulnar canal

A

semi-rigid longitudinal canal in the wrist that allows passage of the ulnar nerve and artery into the hand

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12
Q

where is guyon’s canal found

A

superficial to the flexor retinaculum
- can be palpated just radial (lateral) to the pisiform bone, passing between pisiform and hook of hamate
- roof: formed by palmar carpal ligament

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13
Q

why is guyon’s canal clinically important

A

site of ulnar nerve compression

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14
Q

what is the anatomical snuffbox (aka radial fossa)

A

triangular depression on the radial aspect of the dorsum of the hand, at level of carpal bones
- best seen when thumb is radially abducted

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15
Q

what are the borders of the snuff box

A
  • radial: tendons of abductor pollicis longus (most lateral) and extensor pollicis brevis
  • ulnar: tendon of extensor pollicis longus
  • proximal: styloid process of radius
  • floor: scaophoid and trapezium
  • roof: skin
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16
Q

what are the contents of the anatomical snuff box

A
  • radial artery
  • superficial branch of radial nerve
  • cephalic vein
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17
Q

which arteries supply the hand

A

radial and ulnar artery supply hand via deep and superficial palmar arches

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18
Q

where can the ulnar artery be palpated

A
  • may be palpated as it crosses anterior to flexor retinaculum + ulnar nerve in guyon’s canal
  • here the artery lies radial to pisiform bone and ulnar nerve
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19
Q

in the hand, what does the ulnar artery divide into

A

superficial and deep branches
- both of which anastomose w corresponding branches of the radial artery to form superficial and deep palmar arches

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20
Q

what does the superificial palmar arch give off

A

common palmar digital arteries which supply the fingers

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21
Q

what does the ulnar artery contribute mainly to

A

the superificial palmar arch and therefore to the blood supply of the fingers

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22
Q

how does the radial artery enter the hand

A

between the tendons of brachioradialis and flexor carpi radialis

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23
Q

what does the radial artery give off

A

superficial branch that anastomoses w the superficial palmar arch then passes dorsally to cross the floor of the anatomical snuffbox on the dorsum of the hand before re-entering palm between two heads of adductor pollicis

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24
Q

what does the radial artery anastomose with

A

deep branch of ulnar artery to form deep palmar arch

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25
Q

what does the radial artery mainly contribute to

A

the deep palmar arch and therefore to the blood supply of the thumb and the radial side of the index finger

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26
Q

what are the three branches of the brachial plexus that supply motor and sensory function to the hand

A

median
radial
ulnar

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27
Q

where does the radial nerve arise from

A

posterior divisions of the brachial plexus
- supplies posterior compartment of forearm

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28
Q

where do the median and ulnar nerve arise from

A

anterior divisions of the brachial plexus
- supply the anterior compartment of the forearm and muscles of the hand

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29
Q

what does the ulnar nerve supply

A

all intrinsic muscles of the hand except:
- Lumbrical
- Opponens pollicis
- Abductor pollicis brevis
- Flexor pollicis brevis (superficial head)

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30
Q

what else is the sensory supply to the hand based upon

A

embryological development
- fingernails initially develop on the volar aspect of the hand and are dragged over to the dorsal aspect
- as they migrate, they take their nerve supply with them
- the nailbed and dorsal skin overlying the distal phalanx of each finger is innervated by the nerve that innervates the palmar aspect

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31
Q

where is the nerve supply to the palm of the hand derived from

A

palmar cutaneous branch of the median nerve
- arises proximal to the carpal tunnel
palmar cutaneous branch of the ulnar nerve
- arises proximal to Guyon’s canal

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32
Q

what do the palmar digital branches of the median nerve supply

A

thumb
index finger
middle finger
radial border of ring finger

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33
Q

what do the palmar digital branches of the ulnar nerve supply

A

ulnar border of the ring/little finger
- also innervate the dorsum of these digits over the distal phalanx and nail bed

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34
Q

what does the dorsal cutaneous branch of the ulnar nerve supply

A

skin over the dorsal aspect of the ulnar border of the hand and skin over the dorsum of the ulnar 1 1/2 digits, as far distally as DIPJ

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35
Q

testing sensation in the peripheral nerve territories

A

some overlap between cutaneous territories of the peripheral nerves so always test sensation in the regions known to have a consistent supply:
- radial nerve: dorsum of the first webspace
- median nerve: palmar surface of the tip of the index finger
- ulnar nerve: ulnar border of the hand

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36
Q

scaphoid fractures

A

70-80% of the fractures of the carpal bones and 10% of all hand fractures
- may occur at any age but most common amongst adolescents and young adults following fall onto outstretched hand
- hyperextension and impation of the scaphoid against the rim of the radius or in diret axial compression of the scaphoid

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37
Q

what do pt with scaphoid fracture usually complain of

A

pain in the anatomical snuffbox
- exacerbated by moving the wrist
- passive range of motion is reduced but not dramatcally
- swelling around the radial and posterior aspects of the wrist is common

38
Q

what part of the scaphoid do most fractures affect

A

waist of the scaphoid (70-80%)
- also ocur in proximal pole (20%)
- distal pole (10%) - sometimes alled the scaphoid tubercle

39
Q

X-raying a scaphoid fracture

A
  • plain x-rays immediately after injury may not reveal the fracture so delayed diagnosis is common
  • if initial fracture does not show fracture, obtain follow up after 10-14 days as fracture lines may become more visible after some bone resoprtion
  • but in meantime, treat pt as if they have a fracture
  • if still not clear then use CT or MRI
40
Q

why is there a high risk of avascular necrosis in scaphoid fractures

A
  • blood supply to scaphoid is mainly retrograde from distal to proximal pole
  • since blood supply to the proximal pole is tenuous, fractures through the wasit of the scaphoid can result in avasacular necrosis
41
Q

what is a colles’ fracture

A

an extra-articular fracture of the distal radial metaphysis, with dorsal angulation and impaction
- associated ulnar styloid fracture is present in up to 50% of cases

42
Q

what is there a high risk of w displaced fratures through wasit of scaphoid

A
  • non-union
  • malunion
  • avascular necrosis
  • late complications of carpal instability
  • secondary OA (more common if there has been one of the above)
43
Q

what is the most common type of distal radial fracture

A

Colles’ fracture

44
Q

who are Colles’ fractures common in

A

pt w osteoporosis and they have a reduced bone density
- post-menopausal women
- younger ppl who have this usually involved in high impact trauma e.g. skiing

45
Q

mechanism of injury of Colles’ fracture

A

fall onto outstretched hand (FOOSH) w pronated forearm and wrist in dorsiflexion
- energy transmitted from the carpus to the distal radius in a dorsal direction and along the long axis of the radius = usually dorsally angulated and impacted

46
Q

presentation of Colles’ fracture

A

painful, deformed, swollen wrist

47
Q

Colles’ fracture X-Ray

A
  • fracture line, dorsal angulation and impation are usually clearly visible on plain x-ray, especially at lateral view
48
Q

treatment of Colles’ frature

A

reduction and immobilisation in cast

49
Q

complications of Colles’ fracture

A
  • malunion = dinner fork deformity
  • median nerve palsy and post traumatic carpal tunnel syndrome
  • seondary OA (more common w intra-articular fractures)
  • tear of extensor pollicis longus tendon through attrition of the tendon over a sharp fragment of bone
50
Q

what is a smith fracture

A
  • fractures of the distal radius w volar (palmar) angulation of the distal fracture fragments
  • 85% are extra-articular so can be thought of as reverse Colles’ fracture
  • less than 3% of all radial and ulnar fractures
51
Q

typical mechanism and age group of smith fracture

A
  • young males most common
  • elderly females
  • fall onto dorsum of a flexed wrist or direct blow to bak of the wrist
52
Q

deformity of smith fracture

A

malunion w residual volar displaement of distal radius = cosmetic defomirt referred to as ‘garden spade’ deformity
- narrows and distorts carpal tunnel –> syndrome

53
Q

mechanism of RA

A

autoimmune disease where autoantibodies known as rheumatic factor attack synovial membrane
- inflamed synovial cells proliferate to form pannus –> penetrates through the cartilage and adjaent bone –> joint erosion and deformity
- symmetrical polyarthritis = affecs multiple joints –> can make mild swelling in hand difficult to diagnose as there is no normal hand

54
Q

where does RA particularly affect

A

MCPJ
PIP
cervical spine
can involve large joints

55
Q

what do pt w RA present w

A
  • pain and swelling of PIPJs and MCPJs of fingers
  • erythema overlying joints
  • stiffness, worse in morning or after periods of inativity
  • carpal tunnel syndrome due to synoival swelling
  • fatigue and flu-like symptoms due to systemic nature of siease
  • rheumatic nodules in fingers and over elbow are usually late feature
56
Q

x-ray features of RA

A
  • loss of joint space
  • periarticular osteopenia
  • juxta-articular bony erosions
  • subluxation and gross deformity
57
Q

common deformities seen in pt w advanced RA

A
  • swan neck deformity
  • boutonniere deformity
58
Q

swan neck deformity formation

A

PIPJ hyperextends and MCPJ/DIPJ flexed
- tissues on volar aspect of PIPJ become lax due to adjacent synovitis = primary abnormality
- imbalance between muscle forces acting on PIPJ (extension > flexion) so joint w lax tissues become hyperextended
- at DIPJ, either elongation of rupture of insertion of extensor digitorum into base of distal phalanx = mallet deformity

59
Q

describe formation of Boutonniere deformity

A

MCPJ and DIPJ hyperextension and PIPJ flexion
- inflamm in PIPJ –> lengthening/rupture of the central slip of extensor at its insertion into base of middle phalanc on dorsal surface of finger
- lateral bands of extensor digitorum tendon slip down sides of finger so now on palmar surface at level of PIPJ
- instead of ating as extensors of PIPJ, they start to act as flexors + hyperextending DIPJ$

60
Q

psoriatic arthropathy

A
  • only minority of pt w psoriasis will develop arthritis
  • commonly affects DIPJ
  • when it develops, usually an asymmetrical oligoarthritis meaning it develops in one joint at a time, progressing in asymmetrical manner
  • psoriatic arthritis involves small joints of hands and feet
61
Q

how does a pt w psoriatic arthropathy present

A

fusiform swelling of digits (dactylitis)
- affected joints stiffen and if disease progresses –> widespread joint destruction called arthritis mutilans
onycholysis (separation of nail from nail bed)
pitting

62
Q

what is the most commonly affected joint by OA in the hand

A

1st carpometacarpal joint (between trapzeium and first metacarpal)
- more common in women

63
Q

what will pt w OA of 1st CMCJ complain of

A
  • pain at base of thumb exacerbated by movement, relieved by rest
  • stiffness increases following periods of rest e.g. in mornings
  • mat be some swelling evident around the base of thumb
  • in later stages, 1st metacarpal subluxes in ulnar direction = loss of normal contour and squaring of the hand
64
Q

what are Heberden’s node and how do they develop

A
  • classic sign of 3 affecring DIPJ of fingers
  • typically develop in middle age and more common in women then men
  • tend to run in familiies, suggesting genetic predisposition
  • begin w either a chronic swelling of affected joints/ sudden onset of pain, swelling and loss of manual dexterity
  • intially pt develops cystic swelling containing gelatinous hyaluronic acid on dorsolateral asepct of DIPJ
  • initial inflamm and pain eventually subsides and pt left w an osteophyte
65
Q

what are Bouchard’s nodes

A

same process as Heberden’s nodes developing but in the PIPJs

66
Q

what is carpal tunnel syndrome

A

compression of the median nerve as it passes through the carpal tunnel from the forearm into the hand
- most common site of nerve entrapment in the body

67
Q

what is carpal tunnel syndrome

A

compression of the median nerve as it passes through the carpal tunnel from the forearm into the hand
- most common site of nerve entrapment in the body

68
Q

risk factors of carpal tunnel syndrome (5)

A

obesity
repetitive wrist work
pregnancy
RA
hypothyroidism

69
Q

what can nerve compression result in

A

ischaemia
focal demyelination
decrease in axonal calibre
eventually axonal loss

70
Q

what would a pt w carpal tunnel syndrome experience

A
  • paraesthesia in distribution of median nerve: (thumb, index, middle, radial 1/2 of ring)
  • symptoms often worse at night and can wake pt from sleep
  • as conditions worsen, daily activites e.g. driving, combing hair can aggravate paraesthesia
71
Q

why is sensation to the palm spared in carpal tunnel syndrome

A

palmar cutaneous branch of median nerve branches proximal to carpal tunnel and passes superficial to it into the palm (so not compressed)

72
Q

what can long-standing carpal tunnel syndrome result in

A

muscle weakness and atrophy of thenar muscles (superficial head of flexor pollicis brevis, abductor pollicis brevis and opponens pollicis)

73
Q

what actions will be normal in carpal tunnel syndrome and why

A
  • flexion of thumb: flexor pollicis longus is innervated by anterior interosseus branch of the median nerve in forearm/deep head of flexor pollicis brevis by ulnar nerve
  • adduction of thumb: adductor pollicis supplied by ulnar nerve
74
Q

what nerve can be compressed in guyon’s canal

A

ulnar
- as it passes radial to pisiform bone over the volar surface of the flexor retinaculum
- aka ulnar tunnel syndrome, Guyon’s canal syndrome or handelebar palsy

75
Q

what do pt w ulnar tunnel syndrome complain of

A
  • paraesthesia in the ring and little fingers, progressing to weakness of intrinsic muscles of hand supplied by ulanr (notabily adductor pollicis and palmar/dorsal interossei)
  • also lumbricals to ring and little fingers and deep head of flexor polliis brevis
76
Q

what is dupuytren’s contracture

A

common condition in which there is localised thickening and contracture of the palmar aponeurosis –> flexion deformity of the adjacent fingers

77
Q

how does dupuytren’s contracture develop

A
  • initially = thickening or ‘nodule’ in their palm, which can be painful or painless
  • later, myofibroblasts within nodule contract leading to the formation of tight bands called ‘cords’ in the palmar fascia
  • overlying skin is tightly adherent to palmar aponeurosis and becomes involved –> progresses to involve the proximal fascia and skin of the fingers
  • fingers become stuck in flexed position and cannot be passively straightened
78
Q

most commonly affected digits in dupuytren’s contracture

A

ring and little finger but first websapce and thumb may also be involved
- 40-60yrs
- more common in males
- north eastern origin
- famil history with autosomal dominant inheritance
- remainder of cases = sporadic

79
Q

what are conditions that inc risk of developing dupuytren’s contracture

A
  • type I diabetes
  • epilepsy, taking certain medications e.g. phenytoin, barbiturates
  • liver disease and/or excess alcohol consumption
  • smoking
  • hypercholesterolaemia
  • heart disease
  • HIV
80
Q

describe formation of Boutonniere deformity

A

MCPJ and DIPJ hyperextension and PIPJ flexion
- inflamm in PIPJ –> lengthening/rupture of the central slip of extensor at its insertion into base of middle phalanc on dorsal surface of finger
- lateral bands of extensor digitorum tendon slip down sides of finger so now on palmar surface at level of PIPJ
- instead of ating as extensors of PIPJ, they start to act as flexors + hyperextending DIPJ$

81
Q
A
82
Q

what measurements are relevant in imaging of a distal radius fracture

A
83
Q

what is flexor tendon sheath infection and what is the most common cause

A

inflammation of the tendon sheath
- bacterial infection via S.aureus/epidermis

84
Q

why is flexor tendon sheath infection a surgical emergency

A

raised pressure in the tendon sheath can impair blood flow –> necrosis of tendons and devitalisation of fingers

85
Q

what are common mechanisms of flexor sheath infection

A
  • penetrating trauma
  • direct spread from felons, septic joints
  • haematogenous
86
Q

what are risk factors of flexor sheath infecrion

A
  • diabetes
  • IV drugs
  • immunocompromised
87
Q

what are Kanavel’s signs

A

4 cardinal features of flexor sheath infection:

  1. pain of passive extension of digit (earliest sign)
  2. tenderness on palpation
  3. fusiform swelling
  4. flexed finger
88
Q

what is the immediate and operative management of flexor sheath infection

A
  • immediate: hand elevation and broad spec abx then refer
  • operative: w/in 24 hours surgical flexor sheath washout and samples sent to microbiology
89
Q

what is Froment’s sign

A

used to test function of adductor pollicis muscle
- pinch paper between thumb and index finger against resistance and if the aPL is weak, thumb IP joint will flex

90
Q

what is de Quervain’s tenosynovitis

A

inflammation of the EPB and AbPL tendon sheath causing radial styloid process pain and painful abduction of the thumb against resistance (+ve Finketlstein test)

TRAUMA & ORTHO (11 decks)

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