Conditions of the Wrist and Hand Flashcards
What is dupuytren’s contracture?
Characterized by painless thickening and shortening of the longitudinal fibres of the palmar and digital fascia. As the fascia shortens it can draw the fingers down toward the palm.
What is the development of dupuytren’s contracture associated with?
- Genetic - Viking gene
- Alcohol excess
- Diabetes Mellitus
- Smoking
- Peyronie’s Disease
- Phenytoin Treatment
How does Dupuytren’s contracture present?
- Puckering of the skin
- Gradual flexion - usually of the ring and little fingers
- Functional Problems - Inability to grasp things properly, Loss of finger extension, Can’t put hand in pocket
- Skin pits - fibres attach to skin and pull down pockets
- Boutonnieres deformity
- PIP contracture
How would you treat someone with Dupuytren’s contracture?
Observation
Non-operative
- Radiotherapy
- Collagenase - Ruptures tendon
Operative
- Partial fasciectomy - Good correction
- Dermofasciectomy - Lowest chance of recurrence
- Arthrodesis
- Amputation
Other
- Percutaneous needle fasciotomy
What is trigger finger?
- Stenosing Tenosynovitis
- Swelling/tightening of the tendon sheath, along with nodule formation on the tendon proximal to A1 pulley, prevents tendon from gliding smoothly, causing it to catch ⇒ fixed in flexion
How does trigger finger present?
- Finger gets fixed in flexion
- Released by straightening the finger
How do you treat someone with tigger finger?
Non-operative
- Steroid injection
- Percutaenous release
- Splintage
Operative
- Open surgery
What is De Quervans tenosynovitis?
- Stenosing Tenosynovitis of the 1st extensor compartment - APL and EPB as they cross the radial styloid
- Due to myxoid degeneration of the wall of the tunnel in the extensor retinaculum enclosing APL and EPB ⇒ Becomes grossly thickened
Who does De Quervan’s more commonly present in?
Women - Post partum
How does De Quervan’s commonly present?
- Local tenderness - more proximal than OA of 1st CMC joint
- Finkelsteins test – gripping the thumb in the palm of the hand, then ulnar deviate ⇒positive if painful
- Resisted thumb extension ⇒ Painful
- Pain at styloid worsened by thumb flexion
How do you treat someone with De Quervan’s disease?
Non-operative
- Splints
- Steroids
Operative
- Decompression - protect sensory branch of the radial nerve
What is carpal tunnel syndrome?
- Compression of the median nerve as it passes under the flexor retinaculum of the wrist.
- Can be caused by a variety of things, including thickened ligaments or tendon sheaths, and bone enlargement
Who does carpal tunnel more commonly occur in?
- > 80% older than 40 years
- Female>male - 2:1; women have narrower wrists
What is the aetiology of Carpal Tunnel syndrome?
MEDIAN TRAP
- Myxoedema (hyopthyroidism)
- ETOH (alcohol)
- Diabetes mellitus - neuropathy
- Idiopathic
- Amyloidosis
- Neoplasia - Multiple myeloma, benign tumours
- Trauma - Colle’s fracture, enforced flexion
- Rheumatoid arthritis
- Acromegaly
- Pregnancy (3rd trimester), PMR
How does someone with carpal tunnel syndrome present?
- Numbness and Paraesthesia - thumb, index and middle finger - relieved by dangling hand off the edge of the bed
- Pain -same distribution as numbness; achingin nature, worse at night and after repetitive actions
- Positive Phalen’s test - maximal wrist flexion reproduces symptoms within 60 secs
- Positive Tinel’s sign - tapping flexor aspect of wrist - positive = tingling and pain
- Sensory loss - lateral 31/2 digits
- Thenar Atrophy
How is carpal tunnel syndrome diangosed?
Clinical Diagnosis
- Phalens and Tinels both unreliable, but can help
- Night pain - almost diagnositc
Neurophysiology - helps locate site and severity of lesion
How would you treat someone with carpal tunnell syndrome?
3 S’s - Splint, steroids (local), surgery
Surgery
- Carpal tunnel release
- Open decompression
- Endoscopic
What is cubital tunnel syndrome?
- Compression of the ulnar nerve at the median edge of the elbow, in the ulnar groove
- Stretch and compression of ulnar nerve is moderated by its ability to glide in the groove
What is the general pathophysiology of cubital tunnel syndrome?
Can be caused by
- OA or RA narrowing of ulnar groove ⇒ constriction of ulnar nerve as it passes behind the medial epicondyle
- Friction on ulnar nerve due to cubitus valgus (complication in children after supracondylar fractures) ⇒ Nerve fibrosis ⇒ neuropathy
- Direct trauma
What is the aetiology of Cubital tunnel syndrome?
- Sleeping with the arm folded behind neck, elbows bent.
- Pressing the elbows upon the arms of a chair while typing.
- Resting or bracing the elbow on the arm rest of a vehicle.
- Bench pressing.
- Intense exercising and strain involving the elbow.
How does cubital tunnel syndrome present?
- Sensory loss - over medial 11/2 fingers
- Clumsiness
- Weakness/wasting - Medial wrist flexors (little fingers), Interossei, Medial two lumbricals
- Hyothenar wasting
-
CLAW HAND - severity depends on where lesion is
- Ulnar paradox - more distal the lesion, more severe the claw
How do you manage someone with cubital tunnel syndrome?
General
- Rest
- Avoid pressure on the nerve
- Soft elbow splinting - if continuous (> 6 months)
- Hand Splint - may prevent clawing
Operative
- Decompression
- Nerve re-routing?
What is a ganglion?
- Mucin-filled cyst, often painless swelling caused by a partial tear of the joint capsule or tendon sheath.
- Attached to synovial cavity, but have no synovial lining
How do you treat someone with a ganglion?
- Leave - most resolve on their own within 6 months
- AVOID EXCISION
Where in the hand does OA most commonly present?
1st carpometacarpal joint - thumb
Who is most commonly affected by OA of the base of the thumb?
Women
How does OA of the base of the thumb commonly present?
- Night pain
- Pain associated with use - gripping/twisting e.g. opening jars
- Pain with passive motion
- Crepitus
How does OA of the base of the thumb present on X-ray?
- Loss of Joint Space
- Osteophyte Formation
- Subchondral Sclerosis
- Subchondral Cysts
How would you manage someone with OA of the base of the thumb?
- Simple analgesia
- Surgery - if discomfort disabling
What is the name given to the bony prominence that occurs in OA of the PIP?
Bouchard’s Nodes
What is the name given to the bony prominences that occur in OA of the DIP joint?
Heberden’s Nodes
What are the features of a Colles type fracture?
- Dorsal angulation and displacement
- Radial shortening and deviation
- Supination
How would you reduce a colles type fracture?
- Adequate analgesia
- Exaggerate dorsal angulation while maintaining distal traction
- Correct dorsal and radial angulation while maintaining distal traction
- Apply backslab while maintaining traction - maintain in ulnar deviation with some wrist flexion
- X-ray
What must be obtained if closed reduction of a distal radius fracture is performed?
Post-reduction X-ray
What is a smith’s fracture?
Reversed Colles
- Volar displacement and angulation
How would you manage a smiths fracture?
ORIF - fragments tend to migrate palmarly otherwise
What is a barton’s fracture?
Intra-articular fracture involving the dorsal aspect of the distal radius
What are signs of a scaphoid fracture?
- Tender in anatomical snuff box and over scaphoid tubercle
- Pain on axial compression of the thumb
- Pain on ulnar deviation of pronated wrist
- Pain on supination against resistance
What would you do if you suspected a scaphoid fracture?
Request scaphoid X-ray
How would you manage a scaphoid fracture?
- Nonoperative - thumb spica cast immobilization - stable nondisplaced fracture (majority of fractures)
- Operative - ORIF vs percutaneous screw fixation indications
What analgesia would you consider using in a Colles fracture reduction?
- Haematoma block
- Bier’s Block
How would you follow up a schaphoid fracture managed with a cast?
X-ray - Neutral forearm cast if non-displaced
What is the main complication that can occur with scaphoid fractures?
Avascular necrosis of proximal pole - relies on interosseous supply from the distal part
What can failure to flex the DIP joint against resistance indicate?
FDP division
What can failure to flex PIP against resistance, but DIP flexion is still intact, indicate?
FDS division
How are flexor tendon injuries best managed?
Primary repair - most are open injuries
