Forearm, wrist and hand orthopaedics and trauma

Question 1

What is the name given to a fracture of the radius with dislocation of the ulna at the distal radioulnar joint?

Answer 1

Galeazzi fracture dislocation

Question 2

What is a Monteggia fracture dislocation?

Answer 2

A fracture of the ulna occurs with dislocation of the radial head at the elbow

Question 3

What is the management for a Monteggia fracture dislocation and why?

Answer 3

ORIF, even in children

Manipulation alone has a high recurrence rate

Question 4

What is Dupuytren’s contracture?

Answer 4

A proliferative connective tissue disorder where the specialized palmar fascia undergoes hyperplasia with normal fascial bands forming nodules and cords progressingto contractures at the MCP and PIP joints

Question 5

What is the pathology involved in Dupuytren’s contracture?

Answer 5

Proliferation of myofibroblast cells and the production of abnormal collagen (type 3 rather than type 1)

Question 6

What proportion of cases of Dupuytren’s contracture are bilateral?

Answer 6

50%

Question 7

Which fingers are most commonly involved in Dupuytren’s contracture?

Answer 7

Ring and little fingers

Question 8

Which gender is more affected by Dupuytren’s contracture?

Answer 8

Males 10:1

Question 9

What can cause Dupuytren’s?

Answer 9

Familial - autosomal dominant inheritance

Alcoholic disease

A side effect of phenytoin therapy

Common in diabetics

Question 10

What other fibromatosis is Dupuytren’s associated with?

Answer 10

Peyronie’s disease, which affects the penis

Plantar fibromatosis affecting the feet (Ledderhose disease)

Question 11

When is surgical treatment for Dupuytren’s disease offered?

Answer 11

If contractures are interfering with function

Up to 30° of contracture can be tolerated at the MCP joint and but the PIPJ readily stiffens and any contracture here is usually an indication for surgery

Question 12

What surgical management is avaliable for Dupuytren’s contracture?

Answer 12

Removal of all diseased tissue (fasciectomy)

Division of cords (fasciotomy)

Question 13

What causes trigger finger?

Answer 13

Tendonitis of a flexor tendon to a digit can result in nodular enlargement of the affected tendon, and can get stuck in a fascial pulley, holding the finger in a ‘trigger’ position

Question 14

What fascial pulley is usually involved in trigger finger?

Answer 14

A1

Question 15

What will relieve the symptoms of trigger finger in most patients?

Answer 15

Injection of steroid around the tendon

Question 16

Which site of the hands is very common for development of OA in post-menopausal women?

Answer 16

Distal interphalangeal joints

Question 17

Which metocarpal joint is commonly affected by OA, especially in women?

Answer 17

1st - base of thumb

Question 18

Which joints in the hands tend to be spared by RA?

Answer 18

DIP joints

Question 19

What are the three stages of RA in the hands?

Answer 19

Synovitis and tenosynovitis

Erosions of the joints – inflammatory pannus denudes the joints of articular cartilage

Joint instability and tendon rupture – patients can progress to subluxation and chronic tenosynovitis predisposes to extensor tendon ruptures

Question 20

What are the deformities of the hands seen in RA?

Answer 20

Volar MCPJ subluxation

Ulnar deviation

Swan neck deformity

Boutonniere deformity

Z-shaped thumb

Question 21

What is a swan neck deformity?

Answer 21

Hyperextension at PIPJ with flexion of DIPJ

Question 22

What is Boutonniere’s deformity?

Answer 22

Flexion at PIPJ with hyperextension of DIPJ

Question 23

Which procedure may prevent tendon rupture in the hands in RA?

Answer 23

Tenosynovectomy (excision of synovial tendon sheath)

Question 24

What procedure may be required for distal radio-ulnar joint RA?

Answer 24

Resection of the distal ulna

Question 25

What are ganglion cysts?

Answer 25

Mucinous filled cysts found adjacent to a tendon or synovial joint, commonly found in the hand or wrist

Question 26

What are the most common soft tissue swellings of the hand?

Answer 26

Ganglion cysts

Question 27

Where are giant cell tumours of the tendon sheath found?

Answer 27

They are usually on the palmar surface of the hand Common around the PIP joint of the index and middle fingers

Question 28

Where can giant cell tumours of the tendon sheath spread locally?

Answer 28

They can envelop the digital artery or nerve and erode into bone

Question 29

What is the significance of the radius and ulna being connected proximally and distally by strong ligaments around the proximal and distal radio‐ulnar joints in relation to fractures?

Answer 29

The forearm acts as a ring where if one bone is fractures, there is usually a fracture or dislocation involving the other bone

Question 30

What is a nightstick fracture?

Answer 30

A fracture of the ulnar shaft

Question 31

How might a Nightstick fracture occur?

Answer 31

Direct blow to the ulna

Question 32

What associated injury must be checked for in Nightstick fracture?

Answer 32

Monteggia - dislocation of radial head with the ulnar fracture

Question 33

What treatment is used for a fracture of both bones of the forearm?

Answer 33

Usually requires ORIF with plates and screws Anatomical reduction required to preserve function

Question 34

How can minimally angulated fractures of both bones of the forearm in children be treated?

Answer 34

Plaster only

Question 35

What is a Colles fracture?

Answer 35

An extra‐articular fracture of the distal radius with dorsal displacement

Question 36

What other fracture may be associated with a Colles fracture?

Answer 36

Associated fracture of the ulnar styloid

Question 37

How might minimally angulated/displaced Colles fractures be treated?

Answer 37

Splintage

Question 38

How is a Colles fracture with any angulation past neutral treated?

Answer 38

Manipulation and held in a plaster cast Percutaneous wires or ORIF with plate & screws may be preferred if fracture is particularly unstable

Question 39

What complications can arise from a Colles fracture?

Answer 39

Median nerve compression from stretch of the nerve or a bleed into the carpal tunnel Rupture of the Extensor Pollicis Longus tendon

Question 40

What is Smith's fracture?

Answer 40

A volarly displaced or angulated extra‐articular fracture of the distal radius

Question 41

How does Smith's fracture usually occur?

Answer 41

Falling onto the back of a flexed wrist

Question 42

What is the treatment for Smith's fractures?

Answer 42

ORIF with plate and screws

Question 43

What are Barton's fractures?

Answer 43

Intra‐articular fractures of the distal radius involving the dorsal or volar rim, where the carpal bones of the wrist joint sublux with the displaced rim fragment

Question 44

How can Barton's fractures be classified?

Answer 44

Volar Barton's fractures (an intra-articular Smith's fracture) Dorsal Barton's fracture (an intra-articular Colles' fracture)

Question 45

How do scaphoid fractures usually occur?

Answer 45

Fall onto outstretched hand

Question 46

What are the signs of a scaphoid fracture?

Answer 46

Tenderness in anatomical snuffbox Pain on compressing (telescoping) the thumb metacarpal

Question 47

How is an accurate image of the scaphoid taken?

Answer 47

4 different Xrays are taken AP, lateral and two oblique views

Question 48

What should be done if scaphoid fracture suspected but not shown on Xray?

Answer 48

Splint the wrist Further clinical assessment Repeat Xrays after 2 weeks

Question 49

What are the complications of a scaphoid fracture?

Answer 49

Non-union AVN of proximal pole (its blood supply comes distally)

Question 50

How are displaced scaphoid fractures treated?

Answer 50

Fixed with a special compression screw sunk into the bone to avoid non‐union

Question 51

How are scaphoid non-unions treated?

Answer 51

Screw fixation and bone grafting

Question 52

What is a peri-lunate dislocation?

Answer 52

Dislocation of one of the carpal bones around the lunate

Question 53

How does a peri-lunate dislocation usually occur?

Answer 53

High energy wrist injury resulting from hyperdorsiflexion

Question 54

What will Xrays show in peri-lunate fracture?

Answer 54

A loss of alignment of the capitate and lunate with the concave lunate fossa being empty

Question 55

What is the treatment for peri-lunate dislocation?

Answer 55

Emergency treatment is required with closed reduction and percutaneous pinning or open reduction if closed reduction is not possible

Question 56

What does lunate dislocation show on Xray?

Answer 56

“Spilt cup” sign of the lunate which is usually tilted volarly and empty like a split tea cup

Question 57

How does scapho-lunate dissociation occur?

Answer 57

Rupture of the scapho-lunate ligament

Question 58

What happens if scapho-lunate dissociation is left untreated?

Answer 58

Abnormal forces are placed upon the wrist and carpus and osteoarthritis ensues

Question 59

How is scapho-lunate dissociation treated?

Answer 59

Closed reduction and k‐wiring with or without scapholunate ligament repair

Question 60

What structures are put at risk in a penetrating injury of the volar aspect of the hand?

Answer 60

Flexor tendons Digital nerves Digital arteries

Question 61

What structures are put at risk with penetrating injuries to the dorsum of the hand?

Answer 61

Extensor tendons

Question 62

What extensor tendon injuries in the hand are treated and how?

Answer 62

More than 50% division Surgical repair with splintage in extension for 6 weeks

Question 63

What is mallet finger?

Answer 63

Avulsion of the extensor tendon from its insertion into the terminal phalanx and is caused by forced flexion of the extended DIPJ

Question 64

How does mallet finger present?

Answer 64

Pain Drooped finger Inability to extend the DIPJ

Question 65

What is the treatment for mallet finger?

Answer 65

A mallet splint holding the DIPJ extended which should be worn continuously for a minimum of 4 weeks

Question 66

Which metacarpal fractures are treated conservatively?

Answer 66

3rd, 4th and 5th

Question 67

How do fractures of the 5th metacarpal tend to occur?

Answer 67

A punching injury

Question 68

What degree of flexion in a 5th metacarpal injury can be tolerated without affecting function?

Answer 68

45 degrees

Question 69

Displacement of the 5th metacarpal in which plane should be fixed to avoid functional issues?

Answer 69

Rotational deformity

Question 70

How are metacarpal fractures treated conservatively?

Answer 70

Neighbour strapping of the affected digit to the adjacent finger and early motion to maintain function

Question 71

What treatment should be given in a fight-bite associated with metacarpal fracture?

Answer 71

Surgical washout of the wound to avoid septic arthritis

Question 72

How are most phalangeal fractures managed?

Answer 72

Neighbour strapping Splintage

Question 73

How might intra-articular phalangeal fractures be fixed?

Answer 73

K-wires or small screws

Question 74

How are significantly displaced or angulated phalangeal fractures managed?

Answer 74

Manipulation under anaesthetic