Common Conditions of the Hand and Wrist

Question 1

What are the main features of a Colles’ fracture?

Answer 1

Fracture of the distal radius and ulna
Dorsal displacement and angulation, shortening
FOOSH

Question 2

What are the main features of a Smith’s fracture ?

Answer 2

Fracture of distal radius and ulna
Palmar displacement and angulation, shortening
FOOSH (inward facing hand)

Question 3

 De Quervain’s tenosynovitis

Answer 3

• Inflammation of tendons of thumb (extensor pollicis longus and abductor polliciss tendons)
• Cause is unknown. Repetitive movements likely to make the pain worse. It can also be brought on by a simple strain.
• Symptoms: pain and swelling near the base of the thumb. Movements make the pain worse.
• Diagnosed using: Finkelstein’s test
  Swelling of pollicis longs and pollicis brevis tendons

Question 4

 Scaphoid fracture

Answer 4

In the event of a blow to the wrist (e.g FOOSH), the scaphoid takes most of the force. A fractured scaphoid is more common in the younger population.

The scaphoid has a unique blood supply, which runs distal to proximal. A fracture of the scaphoid can disrupt the blood supply to the proximal portion – this is an emergency. Failure to revascularise the scaphoid can lead to avascular necrosis, and future arthritis for the patient.

The main clinical sign of a scaphoid fracture is tenderness in the anatomical snuffbox.

Question 5

Boxer’s fracture

Answer 5

Fracture of the 5th metacarpal neck. Usually caused by a clenched fist striking a hard object. The distal part of the finger is displaced posteriorly producing shortening of the affected finger.

Question 6

 Carpal tunnel syndrome

Answer 6

Compression of the median nerve within the carpal tunnel can cause carpal tunnel syndrome (CTS). Can be caused by thickened ligaments and tendon sheaths. If left untreated, CTS can cause weakness and atrophy of the thenar muscles.

Clinical features include numbness, tingling and pain in the distribution of the median nerve. The pain will usually radiate to the forearm. Symptoms are often associated with waking the patient from their sleep and being worse in the mornings. There is also thenar muscle wastage.

Tests for CTS can be performed during physical examination:

• Tinel’s Sign
• Phalen’s manoeuvre

Treatment involves the use of a splint, holding the wrist in dorsiflexion overnight to relieve symptoms. If this is unsuccessful, corticosteroid injections into the carpal tunnel can be used. In severe case, surgical decompression of the carpal tunnel may be required.

Question 7

 Dupuytrens contracture

Answer 7

• Flexion contracture of fingers intowards palm
• Cannot be fully extended
• Thickening of the palmar aponeurosis/fascia

Question 8

What is Finkelstein’s test?

Answer 8

Finkelstein’s test is a simple way of diagnosing DeQuervain’s. It can be performed by placing your thumb in the palm of your hand and making a fist around it, then bending your wrist towards your little finger. If this makes the pain by the base of your thumb worse, the test is considered positive.

Question 9

What is Tinel’s sign ?

Answer 9

Tapping the nerve in the carpal tunnel to elicit pain in median nerve distribution (used in carpel tunnel syndrome)

Question 10

What is phalen’s manoeuvre?

Answer 10

Holding the wrist in flexion for 60 seconds to elicit numbness/pain in median nerve distribution (used in carpal tunnel)

Question 11

 Compression of the ulnar nerve in Guyon’s canal

Answer 11

• Nerve trapped in Guyon’s canal at the wrist (anterior to carpal tunnel)
• Loss of sensation of ulnar innervated hand
• Loss of motor function of ulnar innervated intrinsic hand muscles.

Question 12

 Reflex sympathetic dystrophy

Answer 12

• Pain, tenderness and swelling of an extremity
• Associated with sweating, flushing, temperature changes and shiny skin
• Regional pain syndrome

Question 13

What is the hand of benediction?

Answer 13

• Compression of median nerve

- Patient cannot flex 1st/2nd digits when trying to make a fist

Question 14

What is the ulnar paradox?

Answer 14

• Ulnar claw on trying to flatten hand
• Hyperextension of MCP joints 3 and 4 due to unopposed action of extensors (loss of lumbricals)
• Flexion of ICP joints 3 and 4
• Worse deformity is seen on more distal damage

Question 15

Describe the clinical signs of rheumatoid arthritis of the wrist, metacarpophalangeal joints (MCPJs) and proximal interphalangeal joints (PIPJs)


Answer 15

• Symmetrical swelling and tenderness over the MCP, PIP and wrist joints = caused by joint and tendon destruction
• Ulnar deviation of the fingers and wrist = swelling over the MCP joints causes the fingers to become displaced. Extensor tendons subluxate.
• Z deformity of the thumb = hyperextension of ICP joint and fixed flexion and subluxation of the MCP joint
• Swan neck deformity = hyperextension at the PIP and flexion at the DIP joints
• Boutonniere deformity = flexion of the proximal PIP and extension at the DIP joints.

Question 16

What are Heberden’s nodes?

Answer 16

These bony growths are generally found on the finger joints nearest the fingertip, also called the distal interphalangeal or DIP joints. Similar joint swellings located on the lower joint, the proximal interphalangeal or PIP, are called Bouchard’s nodes