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Orthopedics > Common Musculoskeletal Problems: Hand and Wrist > Flashcards

Common Musculoskeletal Problems: Hand and Wrist Flashcards

1
Q

What are the 2 commonest causes of hand pain?

A
  1. Injury

2. Repetitive work-related activities

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2
Q

A patient presents with hand pain associated with pins and needles and numbness. What is the most likely cause?

A
  1. Neurological - arising in wrist, elbow or neck
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3
Q

A patient presents with hand pain and stiffness that is worse in the morning. What is the most likely cause?

A
  1. Tenosynovitis

2. Inflammatory arthritis

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4
Q

List 8 causes of pain in the hand and wrist at all ages

A
  1. Trauma, e.g. fracture
  2. Tenosynovitis
    - Flexor +/- triggering
    - Dorsal
    - De Quervain’s
  3. Carpel tunnel syndrome
  4. Ganglion
  5. Inflammatory arthritis
  6. Raynaud’s syndrome
  7. Chronic regional pain syndrome type I
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5
Q

List 4 causes of pain in the hand and wrist in older patients

A
  1. Nodal OA
    - DIPs (Herbeden’s nodes)
    - PIPs (Bouchard’s nodes
    - 1st CMC joint
  2. Trauma - scaphoid fracture
  3. Pseudogout
  4. Gout
    - Acute
    - Tophaceous
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6
Q

What are 2 main causes of tenosynovitis

A
  1. Repetitive use

2. Inflammatory arthritis

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7
Q

What is tenosynovitis?

A

Inflammation of the synovium surrounding a tendon. Thickened sheaths are often palpable.

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8
Q

How does flexor tenosynovitis typically present?

A
  1. Finger pain when gripping
  2. Finger stiffness in the morning
  3. Trigger finger
    - Commoner in diabetic patients
  4. Palpable + tender tendon nodule usually in distal palm
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9
Q

In which patient group is trigger finger or thumb more commonly found?

A

Diabetics

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10
Q

How is dorsal tenosynovitis classically described?

A
  • Hourglass swelling extending from back of hand
  • Under extensor retinaculum
  • Less common except in RA
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11
Q

In which patient group is dorsal tenosynovitis more commonly found?

A

Patients with rheumatoid arthritis.

Also associated with pregnancy!

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12
Q

How does De Qervain’s tenosynovitis typically present?

A
  1. Pain in wrist
  2. Swelling
  3. Tenderness

…around radial styloid where abductor pollicis longs tendon is held by retaining band.
Pain worsened by flexing thumb into palm.

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13
Q

Which test(s) may be used to diagnose De Qervain’s tenosynovitis?

A

Finkelstein’s test - grasp patient’s thumb and ulnar deviate the hand sharply, as shown in the image. If sharp pain occurs along the distal radius (top of forearm, close to wrist), de Quervain’s tenosynovitis is likely.

Modified Eichoff’s test - ask patient to flex their thumb and clench their fist over the thumb, then ulnar deviate their fist.

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14
Q

What treatment options are available for tenosynovitis?

A
  1. Rest
  2. Splinting
  3. NSAIDs
  4. Physical / occupational therapy
  5. Local steroid injection
    - Alongside tendon under low pressure
  6. Surgical decompression by releasing tendon ( if persistent)
    - A1 pulley in trigger finger
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15
Q

What is the main risk of surgery for De Qervain’s tenosynovitis?

A

Damage to radial sensory nerve during tendon release

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16
Q

What is carpal tunnel syndrome and in which conditions is it commonly seen?

A

A median entrapment neuropathy - usually idiopathic.

But may be caused by thickened ligaments, tendon sheaths or bone enlargement:

  1. Hypothyroidism
  2. Pregnancy (3rd trimester)
  3. Rheumatoid disease
  4. Acromegaly
  5. Amyloid, including dialysis patients
17
Q

How does carpal tunnel syndrome typically present?

A

Typical Hx:

  1. Waking with numbness, tingling and pain
    - Nocturnal
    - Median nerve distribution
    - Radiates to forearm
  2. Fingers feel swollen (but aren’t)

Later features:

  1. Weakness and wasting of thenar muscles
    - Abductor pollicis brevis
  2. Sensory loss in radial 3 1/2 fingers
18
Q

Which test(s) may be used to diagnose carpal tunnel syndrome?

A

Tinnel’s sign - elicited by tapping flexor aspect of wrist, causing tingling and pain

Phalen’s test - symptoms reproduced on passive maximal wrist flexion

19
Q

What treatment options are available for carpal tunnel syndrome?

A
  1. Wrist splint at night
    - Holds wrist in dorsiflexion
    - Diagnostic is relieves symptoms
    - May produce full recovery within several weeks
  2. Local steroid injection
    - Into tunnel - avoid nerve!
    - Helps in 70% but may recur
  3. Surgical decompression
    - If persistent

Pregnancy CTS is often self-limiting as fluid retention subsides postpartum.

20
Q

How does arthritis present in the hand and wrist?

A
  1. Pain, 2. swelling and 3. stiffness

Rheumatoid

  • Symmetrical
  • Wrists, PIPs and MCPs

Psoriatic and reactive

  • Asymmetrical
  • Dactylitis, DIPs, nails

Nodal OA

  • DIPs, PIPs less common, 1st CMC
  • Initially swollen and red
  • Bony swellings persist

1st CMC OA

  • Pain at thumb base during grip
  • Or painless stiffness at base - often in nodal OA
21
Q

Where is pain from scaphoid fractures commonly felt?

A

Snuffbox

22
Q

A patient present with tenderness localised to the anatomical snuffbox in the hand. No abnormalities are seen on X-ray. How do you proceed?

A

Suspect scaphoid # - not always apparent on X-ray initially.

Rx: closed cast for 7-10 days then re-X-ray.

  • If hairline #, healing will be apparent
  • If # still not apparent, CT/MRI/ bone scintigraphy for greater resolution
  • If not healed within 6-12 weeks, surgery is indicated
23
Q

What is the main complication of scaphoid fracture?

A

Avascular necrosis - higher incidence the more proximal; due to retrograde blood supply

24
Q

What is a ganglion and where is the commonest site?

A

A jelly-filled, often painless swelling caused by a partial tear of the joint capsule or tendon sheath.
Wrist is a common site.

25
Q

What are the treatment option for a wrist ganglion?

A

Treatment is not essential - may resolve or cause little trouble.
Surgical excision is an option.

26
Q

What is Dupuytren’s contracture?

A

A painless, palpable fibrosis of the palmar aponeurosis. Causes puckering of the skin and gradual flexion, usually of the ring and little finger.

27
Q

Abnormal signalling in the Wnt pathway is the pathophysiological mechanism underlying which condition?

A

Dupuytren’s contracture - causes fibroblasts to invade the dermis

28
Q

What are the 5 main risk factors associated with Dupuytren’s contracture?

A
  1. Male gender
  2. Caucasian ethnicity
  3. Diabetes mellitus
  4. Alcohol overuse
  5. Peyronie’s disease of the penis
29
Q

What is Peyronie’s disease of the penis and which other condition is it associated with?

A

A painful inflammatory disorder of the corpora cavernosa, eventually leading to painless fibrosis and angulation of the penis during erection

30
Q

What treatment options are available for Dupuytren’s contracture?

A
  1. Intralesional steroid injections
  2. Transcutaneous needle aponeurotomy
  3. Collagenase injection into the collagen contracted cord
    - Improved amount of movement in one RCT
  4. Plastic surgical release
    - Restricted to those with severe deformity of the fingers

Orthopedics (18 decks)

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