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MSK Clinical Conditions > Conditions Of The Hand & Wrist > Flashcards

Conditions Of The Hand & Wrist Flashcards

1
Q

How common are scaphoid fractures? 1️⃣

A

Account for 70-80% of carpal bone fractures

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2
Q

Who are scaphoid fractures most common amongst? 1️⃣

A
  • adolescents

- young children

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3
Q

What is the common mechanism of scaphoid fractures? 1️⃣

A

-FOOSH, resulting in hyperextension and impaction of the scaphoid against the rim of the radius or on direct axial compression of the scaphoid

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4
Q

How do patients with scaphoid fractures present? 1️⃣

A
  • complain of pain in the anatomical snuff box
  • pain exacerbated by moving wrist
  • passive range of motion reduced but not dramatically
  • swelling around the radial and posterior aspects of the wrist
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5
Q

What areas of the scaphoid are fractured? 1️⃣

A
  • most commonly the waist (70-80%)
  • also in the proximal pole 20%
  • or distal pole 10%
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6
Q

How do scaphoid fractures look on X-rays? 1️⃣

A
  • X-rays taken immediately after injury may not reveal the fracture so delayed diagnosis is common
  • if initial X-rays don’t show fracture, follow up X-rays should be obtained 10-14days after because fracture line may become more visible after some bone resorption
  • in the meantime, if fracture clinically suspected, patients should be treated as if they have a fracture
  • after 10-14days, if fracture still not clear from x ray and patient is still symptomatic, CT or MRI may be used
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7
Q

Describe the blood supply of the scaphoid 1️⃣

A
  • major blood supply via dorsal carpal branch of the radial artery
  • supplies proximal 80% of scaphoid via retrograde flow
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8
Q

What is a consequence of the tenuous blood supply to the proximal pole of scaphoid? 1️⃣

A

Displaced fractures through the waist of the scaphoid have a high risk of:

  • non union
  • malunion
  • avascular necrosis
  • late complications of carpal instability and secondary OA
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9
Q

What is a Colles’ fracture? 2️⃣

A

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

  • most common type of distal radial fracture
  • associated ulnar styloid fracture present in 50% cases
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10
Q

Who are Colles’ fractures seen amongst? 2️⃣

A
  • patients with osteoporosis
  • post menopausal women
  • younger patients who present with this fracture have usually been involved in a high impact trauma e.g skiing
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11
Q

What is the mechanism of injury for a Colles’ fracture? 2️⃣

A
  • FOOSH with pronated forearm and dorsiflexed wrist
  • Energy transmitted from carpus to distal radius in a dorsal direction and long the axis of the radius

-fracture is therefore dorsally angulated and impacted

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12
Q

How does a patient with a Colles’ fracture present? 2️⃣

A

-painful, deformed and swollen wrist

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13
Q

How does the Colles’ fracture look on a plain X-ray? 2️⃣

A
  • fracture line
  • dorsal angulation
  • impaction

Clearly visible esp in lateral view

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14
Q

What are the possible complications of a Colles’ fracture? 2️⃣

A
  • malunion, resulting in a ‘dinner fork’ deformity
  • medial nerve palsy and post traumatic carpal tunnel syndrome
  • secondary OA
  • tear of the EPL t.
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15
Q

What are Smith fractures? 3️⃣

A

Fractures of the distal radius with volar (palmar) angulation of the distal fracture fragment

*85% are extra-articulations so can usually be thought of as a ‘reverse Colles’ fracture’

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16
Q

Who do Smith fractures typically occur in? 3️⃣

A
  • most commonly young males

- elderly females

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17
Q

What is the typical mechanism of Smith fractures? 3️⃣

A

-fall onto the dorsum of a flexed wrist
Or
-direct blow to the back of the wrist

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18
Q

What deformity is seen due to malunion of a Smith fracture with residual volar displacement if the distal radius? 3️⃣

A

-‘garden spade’ deformity

This deformity narrows and distorts the carpal tunnel and can result in carpal tunnel syndrome

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19
Q

What does it mean for RA to be described as a ‘symmetrical polyarthritis’? 4️⃣

A
  • it affects multiple joints usually in a symmetrical distribution e.g left and right wrists at same time
  • Symmetrical inflammation can make mild swelling in hand difficult to diagnose as there is no ‘normal’ hand with which to make a comparison
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20
Q

How can patients with RA of the MCPJs and IPJs present? 4️⃣

A
  • pain and swelling of the PIPJs and MCPJs of the fingers
  • erythema overlying joints, indicating inflammation
  • stiffness that is worst in the morning or after periods of inactivity, causing difficulty with tasks such as doing up buttons
  • carpal tunnel syndrome due to synovial swelling
  • fatigue and flu-like symptoms due to systemic nature of RA
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21
Q

State 4 X-ray features of RA 4️⃣

A
  • joint space narrowing
  • perarticular osteopenia
  • juxta-articular (marginal) bony erosions
  • subluxation and gross deformity

*soft tissue swelling can also be inferred from the soft tissue shadow

22
Q

State 2 common deformities seen in patients with advanced RA 4️⃣

A
  • Swan neck deformity

- Boutonniere deformity

23
Q

What deformity occurs in Swan neck deformity? 4️⃣

A
  • PIPJ hyperextended

- MCPJ and DIPJ flexed

24
Q

How does the primary abnormality (hyperextended PIPJ) occur? 4️⃣

A
  • tissues on volar (palmar) aspect of the PIPJ become lax as a result of the adjacent synovitis
  • there is an imbalance between the muscle forces acting on the PIPJ (extension > flexion) so the joint, with its lax tissues on the volar surface, becomes hyperextended
25
Q

How does the DIPJ become flexed? 4️⃣

A
  • @ DIPJ, there is either elongation or rupture of the insertion of ED into the base of the distal phalanx, resulting in a mallet deformity
26
Q

What deformity is seen in Boutonniere deformity? 4️⃣

A
  • MCPJ & DIPJ hyperextended

- PIPJ flexed

27
Q

How does flexion at the PIPJ and hyperextension at the DIPJ arise? 4️⃣

A
  • inflammation in the PIPJ leads to lengthening or rupture of the central slip of the extension digitorum at its insertion into the base of the middle phalanx on the dorsal surface.
  • the lateral bands of the ED t. slip down the sides of the finger so that they are now on the palmar surface at the level of the PIPJ and instead of acting as extensors of the PIPJ, they start to act as flexors of the PIPJ as well as hyperextending the DIPJ
28
Q

What is psoriasis? 5️⃣

A

-skin condition that causes red, flaky patches of skin covered with silvery scales

29
Q

Where do psoriasis patches tend to occur? 5️⃣

A
  • elbows
  • knees
  • scalp
  • lower back

Can occur anywhere

30
Q

What is psoriatic arthritis? 5️⃣

A
  • form of arthritis that affects some people who have psoriasis
  • only a minority of patients with psoriasis develop arthritis
31
Q

What joints are affected in psoriatic arthritis? 5️⃣

A

-commonly the small joints of the hands and feet

Usually develops as an asymmetrical oligoarthritis: develops one joint at a time, progressing in an asymmetrical manner

32
Q

How do patients with psoriatic arthritis present? 5️⃣

A

-fusiform (sausage-shaped) swelling of the digits = dactylitis

  • affected joints stiffen and if the disease progresses, it can progress to a widespread joint destruction = arthritis mutilans
    • DIPJ is most commonly affected

-80% will have nail lesions such as pitting and onycholysis

33
Q

What joint in the hand is most commonly affected by OA? 6️⃣

A

-1st carpometacarpal joint (between trapezium and 1st metacarpal)

More common in women

34
Q

How does OA of the carpometacarpal joint present? 6️⃣

A
  • pain at base of thumb
  • pain exacerbated by movement and relieved by rest
  • stiffness increases following periods of rest
  • some swelling around base of thumb
  • in later stages, 1st metacarpal subluxes in an ulnar direction, resulting in loss of the normal contour and ‘squaring of the hand’
35
Q

How does OA of the fingers present? 6️⃣

A
  • gradual onset of pain in DIPJs as the OA develops
  • stiffness
  • reduced range of movement
  • swelling of affected joints
36
Q

What are Herbeden’s nodes? 6️⃣

A

Bony swelling of the DIPJ

  • classic sign of OA
  • develop in middle age, more common in women, and tend to run in families
37
Q

Describe how Heberden’s nodes develop 6️⃣

A
  • begin with either chronic swelling of the affected joints or a sudden onset of pain, swelling and loss of manual dexterity
  • initially, patient develops a cystic swelling containing gelatinous hyaluronic acid on the dorsolateral aspect of their DIPJ
  • initial inflammation and pain eventually subside and patient is left with an osteophyte
  • when this process occurs in PIPJ instead of DIPJ, it is referred to as Bouchard’s nodes
38
Q

What is carpal tunnel syndrome? 7️⃣

A

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

-most common site of nerve entrapment in the body

39
Q

What are the risk factors for carpal tunnel syndrome? 7️⃣

A
  • obesity
  • repetitive wrist work
  • pregnancy
  • rheumatoid arthritis
  • hypothyroidism
40
Q

What can compression of the median nerve result in? 7️⃣

A
  • ischaemia
  • focal demyelination
  • decrease in axonal calibre and eventually axonal loss
41
Q

What does a patient with carpal tunnel syndrome present? 7️⃣

A
  • paraesthesia in the distribution of the median nerve (thumb, index finger, middle finger and radial half of ring finger)
  • symptoms often worse at night when the wrist drifts into flexion during sleep, narrowing the carpal tunnel further and often wakes patient up
  • as the condition worsens, daily activity such as driving, combing hair, holding a book or phone can aggravate paraesthesia
  • pain can also occur proximally in the forearm, elbow, shoulder and neck in up to one third of patients
  • diminished manual dexterity due to motor and sensory disturbance
42
Q

Why is sensation to the palm spared in carpal tunnel syndrome? 7️⃣

A

-Palmer cutaneous branch of the median nerve branches proximal to the carpal tunnel and passes superficial to it into the palm, so not compressed

43
Q

Why can long-standing carpal tunnel syndrome result in muscle weakness and atrophy of the thenar muscles (FPB, APB, OP)? 7️⃣

A

The motor branch of the median nerve to the thenar muscles exits the median nerve distal to the carpal tunnel

44
Q

What movements of the thumb can the patient still perform despite medial nerve compression? 7️⃣

A
  • flexion of thumb as FPL is innervated by anterior interosseous branch of the median nerve and deep head of FPB innervated by ulnar nerve
  • adduction of thumb as AP is supplied by ulnar nerve
45
Q

Where can the ulnar nerve be compressed? 8️⃣

A

-in Guyon’s canal, as it passes radial to the pisiform over the volar surface of the flexor retinaculum

46
Q

What is ulnar nerve compression in Guyon’s canal known as? 8️⃣

A 
-Ulnar tunnel syndrome
Or
-Guyon’s canal syndrome 
Or
-Handlebar palsy
47
Q

How does a patient with ulnar tunnel syndrome present? 8️⃣

A

-paraesthesia in ring and little fingers, progressing to weakness of the intrinsic muscles of the hand supplied by the ulnar nerve (notably AP, palmar and dorsal interossei, lumbricals to ring and little fingers, and deep head of FPB)

48
Q

What is Dupuytren’s contracture? 9️⃣

A

-condition in which there is localised thickening and contracture of the palmar aponeurosis, leading to a flexion deformity of the adjacent fingers

49
Q

Describe how Dupuytren’s contracture develops 9️⃣

A
  • initially, patient notices a thickening or ‘nodule’ in their palm, which can be painful or painless
  • later in the disease process, myofibroblasts within the module contract, leading to formation of tight bands called ‘cords’ in the palmar fascia
  • the overlying skin is tightly adherent to the palmar aponeurosis and becomes involved in the disease, which also progresses to involve the proximal fascia and skin of the fingers
  • the finger becomes stuck in a flexed position and cannot be passively straightened = ‘fixed flexion’
50
Q

What digits are most commonly affected by Dupuytren’s contracture? 9️⃣

A

-ring and litter finger

But first webspace and the thumb may also be involved

51
Q

Who does Dupuytren’s contracture most commonly occur amongst? 9️⃣

A
  • 40-60 yr old
  • more common in males
  • people of Northern European descent

*70% cases have family history of it and inheritance is autosomal dominant

52
Q

What conditions increase the risk of developing Dupuytren’s contracture? 9️⃣

A
  • Type 1 diabetes
  • having adhesive capsulitis of the shoulder
  • epilepsy, taking certain medications e.g phenytoin
  • liver disease &/or excessive alcohol consumption
  • smoking
  • hypercholesterolaemia
  • heart disease
  • HIV
  • hypo or hyperthyroidism
  • trauma to hand or fingers
  • vibration related hand injury

MSK Clinical Conditions (9 decks)

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