Conditions Of The Wrist + Hand And Surgery Flashcards
What is carpal tunnel syndrome?
Compression of the median nerve as it travels through the carpal tunnel
Basic anatomy of carpal tunnel
- flexor retinaculum forms the superficial border
- between the FR + the carp bones the median nerve + flexor tendons of the forearm travel through the carpal tunnel
- sensation of the palm supplied by the median nerve branches off before the carpal tunnel
Motor + sensory supply of the median nerve
- motor: anterior forearm + thenar muscles
- sensory: radial 3.5 digits of palmar hand + tips of those fingers on dorsum
What are the thenar muscles?
ABductor pollicis brevis
Opponens pollicis
Flexor pollicis brevis
Risk factors of carpal tunnel syndrome `
- obesity
- repetitive strain
- perimenopause
- RA
- diabetes
- acromegaly
- hypothyroidism
Presentation of carpal tunnel syndrome
- numbness, paraesthesia + pain to the finger tips of the radial 3.5 fingers
- worse at night
- weakness of thumb movements
- weakness of grip strength
- thenar eminence atrophy
- difficulty with fine movements involving the thumb
- eases with shaking hands
What 2 special tests can be done in carpal tunnel syndrome?
Phalen’s test
Tinel’s test
What is Phalen’s test?
Hands in reverse pray sign
Hold in position
Numbness + Paraesthesia in median nerve distribution > postiive sign
What is Tinel’s test?
Tapping wrist at location of median nerve over carpal tunnel
Numbness and Paraesthesia in median nerve distribution > positive test
’tinnel’s-tapping
Management of carpal tunnel syndrome
- altered activities
- wrist splints
- steroid injection
- carpal tunnel release surgery: under LA, open or endoscopic, flexor retinaculum is cut to relieve pressure
Surgical management of carpal tunnel syndrome
- carpal tunnel release surgery
- Done under local anaesthesia
- open or endoscopic,
- flexor retinaculum is cut to relieve pressure
What is De Quervain’s tenosynovitis?
Inflammation + swelling of the tendon sheaths in the wrist
Primarily: ABductor pollicis longus + extensor pollicis brevis
What two muscles are primarily involved in De Quervain’s tenosynovitis?
What are their actions?
Abductor pollicis longus + extensor pollicis brevis
Both act to ABduct the thumb + wrist
Risk actors of De Quervain’s tenosynovitis
Female
Age 30-50
Pregnancy
Baby - picking up baby under armpits in between thumb + forefinger
Presentation of De Quervain’s tenosynovitis
- pain near base of thumb
- can radiate up to forearm
- swelling
- aching
- burning
- numbness
- tenderness
- difficulty grasping or pinching
What test is in tenosynovitis?
Finkelstein’s test
Outline finkelstein test
What is it testing ofr?
- pt makes fist with thumb inside fingers
- ulnar deviation of wrist
- pain in radial aspect of wrist is positive sign
- tenosynovitis
Management of de Quervain’s tenosynovitis
- activity modifications - avoid repetitive actions
- wrist splints
- analgesia
- steroid injections
- physiotherapy
- surgical decompression of extensor compartment (rare/last line)
What is Dupuytren’s contracture?
A condition where the fascia of the hand becomes thickened + tight leading to finger contractures - flexed finger deformity
Pathophysiology of Dupuytren’s contracture
- the palmar fascia becomes thicker + tighter + develops nodules
- cord of dense connective tissue pull to finger into flexion + restrict extension
Risk factors of Dupuytren’s contracture
- age
- family history (autosomal dominant)
- male
- manual labour (esp vibrating tools)
- diabetes mellitus 1/2
- epilepsy
- smoking
- alcoholic liver cirrhosis
- phenytoin
Presentation of Dupuytren’s contracture
- hard nodule on the palm
- flexed finger deformity
- impossible to extend finger fully
- most commonly ring finger
What special test is used for Dupuytren’s contracture?
Explain it
Table top test
- Patient ties to lie hand flat on table
- if hand is not completely flat > positive test
- Dupuytren’s contracture
Management of Dupuytren’s contracture
- do nothing
- needle fasciotomy: needle divides + loosens the cord
- limited fasciectomy: removal of abnormal fascia + cord
- dermofasciectomy: removal of abnormal fascia, cord + associated skin > skin graft
What is trigger finger/stenosing flexor tenosynovitis?
A condition where the finger/thumb click or lock when in flexion which prevents a return to extension
Pathophysiology of trigger finger
- most cases are preceded by flexor tenosynovitis > inflammation of the tendon + sheath
- causing thickening of the tendon or tightening on the sheath + nodal formation
- preventing the tendon from moving through the sheath smoothly > locking of the digit
What part of the sheath is most commonly affected in trigger finger?
First annular pulley (A1) in the MCP joint
Risk factors of trigger finger
- women
- increasing age (40-50s)
- diabetes mellitus
- RA
- prolonged gripping hobbies/jobs
Presentation of trigger finger
- painless clicking/catching when trying to extend the finger
- most commonly middle or ring finger
- overtime becomes painful
- stuck in flexed position
- worse in morning + gets better throughout the day
Diagnosis of trigger finger
Clinical diagnosis
History + examination
Management of trigger finger
- rest + analgesia
- splinting - holds finger in extension at night
- steroid injections
- percutaneous trigger finger release
- surgical decompression (severe cases)
What are ganglionic cysts?
Benign soft tissue lumps
Sacs of synovial fluid originating from tendon sheaths or joint capsules
Risk factors of ganglionic cysts
Female
Osteoarthritis
Previous joint or tendon injury
Presentation of ganglionic cysts
- typically in hands + feet
- smooth, spherical painless lump
- non tender
Examination of ganglionic cysts
- spherical non tender lump
- well circumscribed
- transilluminates
Diagnosis + investigations of ganglionic cysts
- diagnosis is mainly clinical
- transillumination
- X ray to rule out other conditions
- USS or MRI
Management of ganglionic cysts
- monitor
- needle aspiration +/- steroid injections
- surgical cyst excision
What is the most common carpal bone to fracture?
Scaphoid
Demographic of scaphoid fractures
Men aged 20-30 in high energy injures
Blood supply to scaphoid
Dorsal branches of the radial artery
Enters in the distal pole
Travel in retrograde fashion to proximal pole
Relationship between location of scaphoid fractures + risk of avascular necrosis
The more proximal the scaphoid fracture
The higher the risk of AVN
Presentation of scaphoid fracture
- sudden onset wrist pain
- bruising
- tenderness in anatomical snuffbox
- pain on palpation of scaphoid tubercule
- pain on telescoping of thumb
Borders of the anatomical snuffbox
- lateral: ABductor pollicis longus + extensor pollicis brevis
- medial: extensor pollicis longus tendon
- floor: scaphoid, trapezium + radial styloid
Contents of the anatomical snuffbox
- radial artery
- superficial radial nerve
- cephalic vein
Investigations of scaphoid fracture
- X-ray - ‘scaphoid series’: AP,lateral + oblique
- if repeat X-ray is negative but clinical suspicion > MRI of wrist
If an X ray does not show a scaphoid fracture but there is strong clinical suspicious, what should you do?
- wrist immobilisation + thumb splint
- repeat X ray in 10-14 days
Management of scaphoid fracture
- undisplaced: strict immobilisation in plaster with thumb splint
- displaced or displaced with high risk of AVN: surgical fixation: percutaneous variable pitched screw
Complications of scaphoid fracture
- avascular necrosis (increased risk if proximal)
- non union
Types of distal radius fractures
Colle’s fracture
Smith’s fracture
Barton’s fracture
Galeazzi fracture
Outline a Colle’s fracture
- extra-articular fracture of the distal radius
- dorsal angulation + dorsal displacement
- FOOSH + forced supination
- dinner fork deformity
Outline a Smith’s fracture
- extra-articular fracture of the distal radius
- volar angulation of the distal fragment
- +/- volar displacement
- FOOSH + forced pronation
- spade deformity
Outline a Barton’s fracture
- intra-articular fracture of the distal radius
- associated dislocation of radio-carpal joint
- volar (more common) or dorsal
Risk factors of distal radius fractures
Related to osteoporosis
- increasing age
- female gender
- early menopause
- smoking
- alcohol excess
- prolonged steroid use
What nerves need to be checked in a distal radius fracture?
- median nerve (incl anterior interosseous nerve)
- ulnar nerve
- radial nerve
How do you assess motor + sensory innveration of the median nerve?
- motor: Ok sign (anterior interosseous branch) + ABduction of thumb
- sensory: index finger
How do you assess motor + sensory innveration of the ulnar nerve?
- motor: Froment’s sign: ask patient to grasp paper with thumb + index finger + pull (paralysis of ADductor pollicis)
- sensory: little finger
How do you assess motor + sensory innveration of the radial nerve?
- motor: extension of thumb
- sensory: dorsal surface of 1st web space
Investigations of distal radius fracture
- X-ray
- CT or MRI in more complex fracture after initial Management
Management of distal radius fractures
- resuscitate + stabilise patient (if trauma case)
- closed reduction in ED
- immobilise + below elbow backslab cast
- Physiotherapy
- ORIF with plating or K wire
Complications of distal radius fractures
- Malunion
- median nerve compression
- osteoarthritis
Describe salter Harris classification
SALTER
- Type I S: Straight through physis
- Type II A: Above - through physis + metaphysis (most common)
- Type III L: Lower - through physis + epiphysis
- Type IV TE: through Everything - through epiphysis, physis + metaphysis
- Type V _R: cRush: crush together
What joints in the hands does rheumatoid arthritis most commonly affect?
MCPJ + PIPJ
Hand deformities in rheumatoid arthritis
- Swan neck: hyperextension of PIPJ + flexion of MCPJ + DIPJ
- Boutonniere’s: Hyperextension pf MCPJ + DIPJ + flexion of PIPJ
- Z thumb deformity
- ulnar deviation
Where in the hand does OA most commonly affect?
1st CMCJ + DIPJs
Between trapezium + 1st metacarpal
Hand deformities in osteoarthritis
- squaring at the CMC joint
- Heberden’s nodes: affects the DIPJ
- Bouchard’s nodes: affects the PIPJ
What is Monteggia fracture?
proximal ulna fracture with dislocation of proximal radial head
what is Galeazzi fracture?
fracture of distal radius with dislocation of distal radioulnar joint
What is a Buckle’s fracture?
incomplete fracture of the shaft of a long bone
characterised by bulging of the cortex
typically in children 5-10
