Common Conditions Of The Hand And Wrist

Question 1

Where do patients with a scaphoid fracture most commonly complain of pain?

Answer 1

The anatomical snuff box

Question 2

Describe the distribution of the most common scaphoid fractures

Answer 2

• 70-80% occur at the scaphoid waist
• 20% at the proximal pole
• 10% at the distal pole

Question 3

Why can fractures through the scaphoid waist cause avascular necrosis?

Answer 3

Blood supply is retrograde from the distal to proximal pole so proximal end can loose blood supply when broken

Question 4

What is a Colle’s fracture?

Answer 4

An extra-articular fracture of the distal radial metaphysis, with dorsal angulation and impaction

Question 5

What group of people are Colle’s fractures most common in?

Answer 5

Common in patients with osteoporosis, especially post-menopausal women

Question 6

Describe how a Colle’s fracture looks

Answer 6

Looks like a dinner fork

Dorsally angulated and impacted

Question 7

What is a Smith’s fracture

Answer 7

A fracture of the distal radius with palmar angulation of the distal fracture

Question 8

How do smith’s fractures usually occur?

Answer 8

FOOSH onto a flexed wrist

Question 9

What cosmetic deformity can result from a Smith’s fracture

Answer 9

With malunion of a Smith’s fracture you see garden spade deformity → residual volvular displacement

It can cause carpal tunnel syndrome

Question 10

Which joints does rheumatoid arthritis mainly affect?

Answer 10

The metacarpophalangeal (MCPJ) and the proximal interphalangeal joints (PIPJ)

Question 11

Give 4 X-ray features of rheumatoid arthritis

Answer 11

1. Joint space narrowing
2. Periarticular osteopenia (evidence of inflammation)
3. Marginal bony erosions
4. Subluxation (partial dislocation) and gross deformity

Question 12

What 2 deformities will you are in a rheumatoid arthritis hand?

Answer 12

• Swan neck deformity
• Boutonniere deformity

Question 13

What happens to the finger joints to cause swan neck deformity

Answer 13

The PIP joint hyperextends whilst the MCP and DIP joints are flexed

Question 14

What happens to the finger joints in BOUTONNIERRE deformity

Answer 14

The MCP joint and DIP joints are hyperextended whilst the PIP joint is flexed

Question 15

What is psoriatic arthropathy?

Answer 15

Arthritis developing in a minor proportion of patients who have psoriasis

Question 16

Which joints are more commonly affected in psoriatic arthropathy?

Answer 16

The DIP joints (Opposite to RA)

Question 17

How does psoriatic arthropathy present?

Answer 17

Patient will have:

• fusiform (sausage shaped) swelling of digits called dactylitis
• affected joints are stiff
• 80% of patients have nail lesions e.g. pitting and onycholyosis (separation of nail from the nail bed)

Question 18

Which joint of the hand is most commonly affected by osteoarthritis?

Answer 18

The 1st carpometacarpal joint (between the trapezium and 1st metacarpal)

Question 19

What will patients complain of if they have osteoarthritis of the 1st CMC joint?

Answer 19

• Pain at the base of the thumb
• exacerbated by movement
• relieved by rest
• stiffness increasing following long periods of rest

Question 20

What happens in late stage osteoarthritis of the 1st CMC joint?

Answer 20

The 1st metacarpal subluxes in an ulnar direction Causes the hand to ‘square’

Question 21

What are Heberden’s nodes?

Answer 21

A sign of osteoarthritis affecting the DIP joints

• chronic swelling of affected joint
• loss of manual dexterity
• initial cyst develops containing hyaluronic acid
• once initial inflammation subsides the patient is left with an osteophyte

Question 22

What are Bouchard’s nodes?

Answer 22

The same as Heberden’s nodes but in the PIP joint

Question 23

What is carpal tunnel syndrome?

Answer 23

Compression of the median nerve as it passes through the carpal tunnel in the forearm into the hand

Question 24

Give some risk factors of developing carpal tunnel syndrome

Answer 24

• obesity
• pregnancy
• repetitive wrist work
• RA
• hypothyroidism

Question 25

What will a patient with carpal syndrome complain of?

Answer 25

* **Paraesthesia** in the distribution of the median nerve (thumb, index finger, middle finger and radial half of the ring finger) * Symptoms often worse at night * Daily activities can aggregate the pain

Question 26

What is the palm not affected in carpal tunnel syndrome?

Answer 26

The **palmar cutaneous branch** of the median nerve **branches proximal to the carpal tunnel** so isn’t compressed

Question 27

Why does long standing carpal tunnel syndrome cause muscle wasting of the thenar muscles? (OAF)

Answer 27

The motor branch of the median nerve that supplies the thenar muscles branches **distally** to the carpal tunnel and is therefore compressed in carpal tunnel syndrome

Question 28

What nerve is compressed in Guyon’s canal? What is the syndrome called?

Answer 28

**The ulnar nerve** - known as ulnar tunnel syndrome, ## Footnote **Guyon’s canal syndrome or Handlebar palsy**

Question 29

Where will the patient report paraesthesia in Guyon’s canal syndrome?

Answer 29

In the **ring and little fingers** Will also affect the adductor pollicis, palmar and dorsal interossei, and lumbricals of the ring and little fingers

Question 30

What is Dupuytren’s contracture?

Answer 30

**Localised thickening** and **contracture** of palmar aproneurosis leading to a **flexion deformity** of adjacent fingers

Question 31

Which digits are most commonly affected in Dupuytren’s contracture?

Answer 31

The **ring and little finger** but the **1st web space** of the thumb can also be involved

Question 32

Give 4 risk factors for developing Dupuytren’s contracture

Answer 32

1. Type 1 diabetes 2. Liver disease / excessive alcohol consumption 3. Smoking 4. Hypercholesterolaemia

Question 33

Will a patient be able to extend their elbow in fracture of the **mid shaft of the humerus**? Explain your answer

Answer 33

**Yes extension will be normal** The radial nerve branch that supplies the triceps is _given off before the radial nerve enters the spiral groove_

Question 34

If the radial nerve **is** damaged in **humeral fracture,** what position will the patients wrist and fingers be in when the wrist is pronated?

Answer 34

Wrist and fingers will be **flexed known** as **wrist drop** Radial nerve paralysis of brachioradialis and all extensor muscles of the wrist and fingers

Question 35

Describe the distribution of **sensory impairment** in radial nerve damage due to humerus fracture

Answer 35

In the area innervated by the **superficial radial nerve** branch i.e. thumb, index, middle and half of ring finger (posteriorally) NOT including the finger tips

Question 36

What muscles will be paralysed if the **median nerve** is damaged in a **supracondylar fracture?**

Answer 36

All muscles supplied by median nerve in the forearm and hand * pronator teres * flexor carpi radialis * palmaris longus * flexor digitorum superficialis

Question 37

Where would you test sensation for the following nerves? Radial, Median, Ulnar

Answer 37

* **Radial nerve** - Dorsum of 1st web space * **Median nerve**- palmar surface of tip of the index finger * **Ulnar nerve**- ulnar border of the hand

Question 38

If the median nerve is damaged in a **supracondylar fracture,** explain how the hand may look and why

Answer 38

**The Hand of Benedicition** Flexor digitorum superficialis is paralysed in all 4 fingers. Flexor digitorum profundus is only paralysed in the **index** and **middle** fingers. Flexor Policis Longus is also paralysed When asked to make a fist, only the ring and little finger can flex

Question 39

How would the hand appear in an **low injury** to the **median nerve** (i.e. at the wrist)

Answer 39

**Ape hand deformity** Flattening of the thenar emnince, thumb is **adducted** and **externally rotated** _Appearance is different from a supracondylar fracture injury to median nerve as the branches supplying muscles of the forearm have already branched_

Question 40

How may the hand appear in an injury to the ulnar nerve at the wrsit (low ulnar injury). Explain why

Answer 40

**Ulnar Claw** * The ring and little fingers of the hand are **flexed** at the PIP and DIP joints due to **unnapposed flexion** from **flexor digitorum superficialis** and **flexor digitorum profundus** * They are **extended** at the MCP joints due to **unnopposed extension** from **extensor digitorum**

Question 41

How may the hand appear in a **high inury** to the ulnar nerve (at the elbow)

Answer 41

**High ulnar claw** **All** the muscles supplied by ulnar nerve in the hand, as well as injury to **flexor carpi ulnaris** and **ulnar half of flexor digitorum profundus** (there is no flecusion of DIPJ of the ring and little fingers)

Question 42

Explain the ulnar paradox

Answer 42

A high ulnar injury (at the elbow) will have a **less pronounced deformity** even though **more** muscles have been paralysed compared to a low ulnar injury (at the wrist) in which **less muscles** are paralysed by the **deformity is greater**