Elbow, Hand and Wrist I-IV Flashcards
Proximal Carpal Row
Scaphoid, lunate, triquetrum, pisiform
Distal Carpal Row
Trapezium, trapezoid, capitate, hamate
Carpal Motion in Flexion
Scaphoid flexes further, rest of proximal row remains straight
Radial Deviation
Scaphoid moves more vertically on lateral x-ray (flexes out more)
Pulls lunate with causing flexion also
Proximal row flexes
Ulnar Deviation
scaphoid has less than 45 degree angulation
pulls lunate into extension
Trequitrum drops under hamate (extends)
Entire proximal row extends
DISI
Disruption of sorsal portion of the scapho-lunate interosseous ligament and radioschophocapitiate ligament
Pathologic gapping between scaphoid and lunate
Lunate twisted dorsally
Test integrity placing thumb over scaphoid tubercle and index finger on dorsum of hand
Scaphoid will move vertically and be felt by index finger
VISI
disruption of dorsal portion of the luno-triquetral interosseous ligament
longitudinal metacarpal arch, pull of interosseous, tendon insertions proximally
Phalanges
Pull of lumbrical and interosseous muscles provide a deforming force on fractures of the proximal phalanx
Thumb Metacarpal
Carpal fracture due to tendons
Avulsion caused by APL
Extrinsics
MP joint extension
Intrinsics
Flex MP joints
Extend IP joints
Swan Neck Deformity
PIP joint hyperextension
DIP joint flexion
Dorsal subluxation of lateral bands
Rheumatoid Arthritis
PIP synovitis with dorsal displacement of lateral bands
Mallet Injury
Proximal retraction of lateral bands due to loss of distal anchor (terminal tendon)
Extensory band shifts proximally (increasing resting tone of extensors) and over time wears out restraining the ligaments
Causing swan neck to develop, ligaments can wear out restraining ligaments, swan neck develops
Bouonierre Deformity
PIP flexion
DIP Hyperextension
Injury to central slip with volar subluxation of lateral bands
Tender to palpation over the middle phalanx-presume boutinierre splint in extension
With rhematoid arthritis PIP joint synovitis with central slip rupture or volar subluxation
Boutonierre Trauma
Axial load injury
Triangular ligament tear or central slip extensor tear
Cubital Tunnel Syndrome
Tinels sign, elbow hyperflexion test (hyperflex elbow 1 minute, look for tingling, 1st dorsal interosseous and FCU weakness when severe
Nerve conduction velocity NCV and EMG usually negative except when advanced stage
Capal Tunnel Syndrome
Thumb/middle finger paresthesias
Symptoms worse at night
Drop things/hand clumsiness
Paresthesias while driving
Carpal Tunnel Exam
Tinels Pgalens Carpal tunnel compression test APB strength NCV/EMG usually positive
Carpal Tunnel Etiology
Metabolic diabetes Hypothyroidism Pregnancy Idiopathic/multifactorial Occupational Flexor tenosynovitis
Carpal Tunnel Findings
Weakness of abductor pollicis brevis
Carpal Tunnel Treatment
Cock up splint Activity modification/ergonomics NSAID Injection Surgical release of TCL
Flexor Tenosynovitis
Highly repetivie finger motions
Prolonged gripping
Thyroid disorders
Diabetes
Trigger Fingers
Flexor tendon swells and is too big to get under pulley band
Flexor pulley system
Tucking fingers in tight when flexing
Patient unable to extend affected finger
Trigger Finger History
Diabetes, hyper extension strain, contusion, overuse of digit
Treatment
NSAID, injection, release of A-1 pulley
De Quervain’s Disease
1st dorsal compartment DC1 tenosynovitis/impingement
Caused by trauma, overuse, retinacular ganglion cystm radial styloid spur
De Quervain’s Pt. History
2 hands lifting with forearms in neutral rotation New mother Trauma to radia lwrist Ulnar deviation strain Tingling/burning dorsal thumb and index
De Quervain’s Disease PE
Finkelstein’s maneuver
Pain with resisted APL, EPB
Palpatory tenderness over DC1
De Quervain’s Treatment
Long opponenes (forearm based thumb spica) splint
NSAD
Injection
Release of DC
Thumb CMC Joint Pathology
Pain at base of thumb and thenar palm
Worse with pinching
Synovitis, laxity of anterior oblique ligament, women»_space;men, degenerative disease
Thumb CMC Joint Pathology History
Pain with pinching/holding
Manipulates small parts all day
Thumb CMC Clinical Findings
Palpatory joint tenderness Grind test Distraction-torque test Laxity of CMC joint Radiographs (static stress more common in nondominant hand)
Thumb CMC treatment
Modify activity Short opponens splin NSAD Injection Surgery (reconstruct ligament, excise trapezium)
Tests for Radial, MEdian and Ulnar Nerves
- Make OK sign (median nerve)
2. Cross fingers (radial (extends fingers), ulnar (cross them))
Dupuytren’s Disease
Overuse of wrist and hand muscles
Progressive fibro-proliferative disease leads to characteristic cord and nodule formation in palm and fingers
Collagen deposition thickens the cords which contracts the tissue tightly, pulling fingers into flexion
Ulnar Claw Hand
Clawing of ulnar digits (4-5)
Ulnar nerve impingement in cubital tunnel
Pt. presents with clawing (hyperextension of MP joints 4/5, flexing of IP joints)
Ulnar Claw Treatment
Modify activity Avoid elbow flexion beyond 30 degrees Night splint NSAID Surgery
Mallet Finger
Finger droops at the tip due to injury to terminal extensor mechanism
Mallet Finger History
Inability to extend DIP joint, sports related injury, minor trauma
Mallet Finger PE
Tenderness at site of injury
Passive extension intact
Hyperextension may present in PIP joint (compensatory swan neck deformity)
Mallet Finger treatment
Splint DIP in slight hyperextension
Only DIP joint, leave PIP free
Surgery
Origin of wrist extensors
From lateral epicondyle of humerus and all innervated by radial nerve
Long finger flexors origin
medial epicondyle and innervated by median and ulnar nerves
Intrinsic ligaments
Connect bone-bone
Extrinsic ligaments
Thickening in capsules of wrist
Hook of hamate
Found 1 cm distal and 1 cm radial from the pisiform
Should feel like a pea if you roll finger over that area
Interosseous muscles
Primary flexors of MP joint
Lumbricals
Help take tension off flexor tendons
Easier to extend the fingers
