Common Conditions Of The Wrist Flashcards
What is a scaphoid fracture , what causes a scaphoid fracture , presentation and complications ?
- Scaphoid fracture is the the break of the scaphoid bone in the wrist.
- The cause is often a fall on the outstretched hand.
- Present with pain at the base of the thumb with worse use of the hand. Anatomical snuff box tender.
- Complications could be avascular necrosis because blood supply to the scaphoid is mainly retrograde from the distal to the proximal pole. And since the blood supply to the proximal pole is tenuous , fractures through the waist of the scaphoid can result in avascular necrosis. This could lead to non-union ( fracture does not heal). This increases risk of osteoporosis.
What is a colles fracture ?
- Extra-articular fracture of the distal radius with dorsal angulation of the distal radius.
Cause : fall on outstretched hand with a pronated forearm and wrist in dorsiflexion. Predominantly elderly women or young adults. Risk factor is osteoporosis , thus more frequently seen in post menopausal women. Sometimes involved with high impact trauma eg skiing.
Presentation : pain , bruising , swelling , dinner fork deformity
What is a smiths fracture ?
- Extra articular fracture of the distal radius with palmar angulation of distal fragment.
- Cause if falling into wrist whilst flexed or fall onto the Dorsum. Rare , less than 3%. More common in young males and elderly females.
- Presentation , pain , bruising , garden spade defomority.
What is rheumatoid arthritis? And what joints does it mainly affect
- An autoimmune disease in which autoantibodies known as rheumatoid factor attack the synovial membrane. The inflamed synovial cells proliferate which forms a Pannus. This penetrates through cartilage and adjacent bone leading to joint erosion and deformity.
- Mainly affects the metacarpophalangeal joints and proximal interphalangeal joints of the hands and feet. And the cervical spine.
Why is rheumatoid arthiris usuallyhard to diagnose in a swollen hand ?
Because it is ‘ symmetrical polyarthiris’
Meaning that it affects multiple joints in symmetrical distribution , so you cannot compare the swollen hand to a normal hand because there is normal hand.
Patients with rheumatoid arthritis in PIPJ and MCPJ usually present with what symptoms ?
- Pain and swelling
- Redness overlying the joints
- Carpal tunnel syndrome.
- Fatigue and flu like symptoms.
In an x-ray , what are you likely to find in someone with RA ?
Joint space narrowing
- Soft tissue shadow , which indicates soft tissue swelling.
- Periarticular osteopenia
What are the two most common deformities seen in patients with advanced RA ?
- Swan neck deformity
2. Boutonnière deformity
What is swan neck defomormity ?
This is where the PIPJ hyperextends and the MCPJ and DIPJ are flexed.
What is boutonnières deformity ?
MCPJ and distal interphalangeal joint are hyperextended and the PIPJ is flexed.
What is psoriatic arthropathy?
Psoriasis is a skin condition that causes red , flatly patches of skin covered in silver scales.
Only a minority of patients with psoriasis will develop arthritis. When it does develop , it is usually asymmetrical oligoartthiris where it develops in one joint at a time.
Unlike RA ( which normally affects PIPJS and MCPJS) , PA most commonly affects DIPJS. 80% of patients also have nail lesions such as pitting and onycholysis ( separation of nail from nail bed)
What joint in the hand is most commonly affected by osteoarthritis?
The first carpometacarpal joint ( between the trapezium and the first metacarpal). This is more common in women than men.
The patient complains of pain at the base of the thumb , the pain is exacerbated by movement and relieved at rest. Stiffness increases following periods of rest. Can also lead to squaring of the hand due to first metacarpal subluxes in the ulnar direction.
What is heberdens nodes ?
A very classic sign of osteoarthritis and affects the DIPJ of the fingers. More commonly affect women than men.
Initially , the patient develops cystic swelling containing gelatinous hyaluroic acid on the dorsolateral aspect of their DIP joint. The initial inflammation and pain subside and the patient is left with an osteophyte.
When the same process of formation of heberdens nodes occurs in the proximal interphalangeal joint occurs , what is it called ?
Bouchard nodes
What is carpal tunnel syndrome ?
Compression of the median nerve as it passes through the carpal tunnel from the forearm into the hand. It is the most common site of nerve entrapment in the body.
What are risk factors for carpal tunnel syndrome ?
Obesity
Repetitive wrist work
Pregnancy
RA
Hypothyroidism
What will a patient complain of in carpal tunnel syndrome ?
- Paraesthesia in the distribution of the median nerve ( thumb , index finger , middle finger and radial half of the ring finger ). Symptoms are worst at night when the wrist drifts into flexion during sleep , narrowing the carpal tunnel further.
- Long standing carpal tunnel syndrome can result in muscle weakness and atrophy of thenar muscles ( OAF - opponens polices , abductor pollicis brevis and flexor pollicis brevis ( superficial head).The patient will still be able to flex their thumb though as the deep head of the flexor pollicis brevis is innervated by the ulnar nerve and adduction of the thumb is spared as adductor pollicis is supplied by ulnar nerve.
- Importantly , the palm is usually spared as the palmar cutaneous branch does not travel through the carpal tunnel.
What is ulnar nerve compression in guyons canal ?
Also known as ulnar ulnar tunnnel syndrome .or handlebar palsy.This is where the ulnar nerve gets compressed in Guyons canal.
Someone with ulnar tunnel syndrome , what will they present with ?
Patient will report with paraesthesia in the ring and little fingers , progressing to weakness of the intrinsic muscles of the hand supplied by the ulnar nerve ( adductor pollicis , palma and dorsal interrossi , lumbircals to ring and little fingers and deep head of flexor pollicis brevis )
What is Dupuytrens contracture?
This is where there is localised thickening and contracture of the palmar aponeurosis leading to a flexion deformity of adjacent fingers.
Initially , the patient notices a thickening or nodule in their palm which can be painful , later in the disease process the myofibroblasts within the nodule contract leading to the formation of tight bands called cords in the palmar fascia.
The fingers eventually become stuck in the flexed position.
It is more common in males and in persons of Northern European origin.
Inheritance is autosomal dominant.
Digits most commonly affected are the ring and little fingers
What conditions increase the risk of Dupuytren’s contracture ?
Type 1 diabetes
Smoking
Heart disease
Hypo/hyperthryoidism
HIV
epilepsy medications such as phenytoin
How to test for carpal tunnel syndrome ?
- Tunnel-s sign : tapping the nerve in the carpal tunnel to elicit pain in median nerve disturbution
- Phalen-s manoeuvre : holding wrist in flexion for 60s will elicit numbness / pain in median nerve.
What are the sensory affects of damage to the median nerve at the elbow , eg through a supra condylar fracture of the humerus ?
Lack of sensation over the areas that the median nerve innervates eg the thumb , index finger , middle finger and half of the ring finger.
What are the motor effects of damage to the median nerve at the elbow ?
- All flexors and pronators in the forearm will be paralysed. With the exception of the flexor carpi ulnaris ( because it is innervated by the ulnar nerve ) and the ulnar half of the flexor digitorium profundus.
- The forearm is constantly supinated.
- Wrist flexion is weak.
- Flexion at the thumb is also prevented as both the flexor pollicis longus and brevis muscles are paralysed.
- The lateral two lumbricals are affected and the patient will not be able to flex at the MCP joints or extend at the IP joints of the index and middle fingers.
