Forearm, wrist and hand orthopaedics and trauma Flashcards
What is the name given to a fracture of the radius with dislocation of the ulna at the distal radioulnar joint?
Galeazzi fracture dislocation
What is a Monteggia fracture dislocation?
A fracture of the ulna occurs with dislocation of the radial head at the elbow
What is the management for a Monteggia fracture dislocation and why?
ORIF, even in children
Manipulation alone has a high recurrence rate
What is Dupuytren’s contracture?
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
What is the pathology involved in Dupuytren’s contracture?
Proliferation of myofibroblast cells and the production of abnormal collagen (type 3 rather than type 1)
What proportion of cases of Dupuytren’s contracture are bilateral?
50%
Which fingers are most commonly involved in Dupuytren’s contracture?
Ring and little fingers
Which gender is more affected by Dupuytren’s contracture?
Males 10:1
What can cause Dupuytren’s?
Familial - autosomal dominant inheritance
Alcoholic disease
A side effect of phenytoin therapy
Common in diabetics
What other fibromatosis is Dupuytren’s associated with?
Peyronie’s disease, which affects the penis
Plantar fibromatosis affecting the feet (Ledderhose disease)
When is surgical treatment for Dupuytren’s disease offered?
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
What surgical management is avaliable for Dupuytren’s contracture?
Removal of all diseased tissue (fasciectomy)
Division of cords (fasciotomy)
What causes trigger finger?
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
What fascial pulley is usually involved in trigger finger?
A1
What will relieve the symptoms of trigger finger in most patients?
Injection of steroid around the tendon
Which site of the hands is very common for development of OA in post-menopausal women?
Distal interphalangeal joints
Which metocarpal joint is commonly affected by OA, especially in women?
1st - base of thumb
Which joints in the hands tend to be spared by RA?
DIP joints
What are the three stages of RA in the hands?
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
What are the deformities of the hands seen in RA?
Volar MCPJ subluxation
Ulnar deviation
Swan neck deformity
Boutonniere deformity
Z-shaped thumb
What is a swan neck deformity?
Hyperextension at PIPJ with flexion of DIPJ
What is Boutonniere’s deformity?
Flexion at PIPJ with hyperextension of DIPJ
Which procedure may prevent tendon rupture in the hands in RA?
Tenosynovectomy (excision of synovial tendon sheath)
What procedure may be required for distal radio-ulnar joint RA?
Resection of the distal ulna
What are ganglion cysts?
Mucinous filled cysts found adjacent to a tendon or synovial joint, commonly found in the hand or wrist
What are the most common soft tissue swellings of the hand?
Ganglion cysts
Where are giant cell tumours of the tendon sheath found?
They are usually on the palmar surface of the hand
Common around the PIP joint of the index and middle fingers
Where can giant cell tumours of the tendon sheath spread locally?
They can envelop the digital artery or nerve and erode into bone
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?
The forearm acts as a ring where if one bone is fractures, there is usually a fracture or dislocation involving the other bone
What is a nightstick fracture?
A fracture of the ulnar shaft
How might a Nightstick fracture occur?
Direct blow to the ulna
What associated injury must be checked for in Nightstick fracture?
Monteggia - dislocation of radial head with the ulnar fracture
What treatment is used for a fracture of both bones of the forearm?
Usually requires ORIF with plates and screws
Anatomical reduction required to preserve function
How can minimally angulated fractures of both bones of the forearm in children be treated?
Plaster only
What is a Colles fracture?
An extra‐articular fracture of the distal radius with dorsal displacement
What other fracture may be associated with a Colles fracture?
Associated fracture of the ulnar styloid
How might minimally angulated/displaced Colles fractures be treated?
Splintage
How is a Colles fracture with any angulation past neutral treated?
Manipulation and held in a plaster cast
Percutaneous wires or ORIF with plate & screws may be preferred if fracture is particularly unstable
What complications can arise from a Colles fracture?
Median nerve compression from stretch of the nerve or a bleed into the carpal tunnel
Rupture of the Extensor Pollicis Longus tendon
What is Smith’s fracture?
A volarly displaced or angulated extra‐articular fracture of the distal radius
How does Smith’s fracture usually occur?
Falling onto the back of a flexed wrist
What is the treatment for Smith’s fractures?
ORIF with plate and screws
What are Barton’s fractures?
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
How can Barton’s fractures be classified?
Volar Barton’s fractures (an intra-articular Smith’s fracture)
Dorsal Barton’s fracture (an intra-articular Colles’ fracture)
How do scaphoid fractures usually occur?
Fall onto outstretched hand
What are the signs of a scaphoid fracture?
Tenderness in anatomical snuffbox
Pain on compressing (telescoping) the thumb metacarpal
How is an accurate image of the scaphoid taken?
4 different Xrays are taken
AP, lateral and two oblique views
What should be done if scaphoid fracture suspected but not shown on Xray?
Splint the wrist
Further clinical assessment
Repeat Xrays after 2 weeks
What are the complications of a scaphoid fracture?
Non-union
AVN of proximal pole (its blood supply comes distally)
How are displaced scaphoid fractures treated?
Fixed with a special compression screw sunk into the bone to avoid non‐union
How are scaphoid non-unions treated?
Screw fixation and bone grafting
What is a peri-lunate dislocation?
Dislocation of one of the carpal bones around the lunate
How does a peri-lunate dislocation usually occur?
High energy wrist injury resulting from hyperdorsiflexion
What will Xrays show in peri-lunate fracture?
A loss of alignment of the capitate and lunate with the concave lunate fossa being empty
What is the treatment for peri-lunate dislocation?
Emergency treatment is required with closed reduction and percutaneous pinning or open reduction if closed reduction is not possible
What does lunate dislocation show on Xray?
“Spilt cup” sign of the lunate which is usually tilted volarly and empty like a split tea cup
How does scapho-lunate dissociation occur?
Rupture of the scapho-lunate ligament
What happens if scapho-lunate dissociation is left untreated?
Abnormal forces are placed upon the wrist and carpus and osteoarthritis ensues
How is scapho-lunate dissociation treated?
Closed reduction and k‐wiring with or without scapholunate ligament repair
What structures are put at risk in a penetrating injury of the volar aspect of the hand?
Flexor tendons
Digital nerves
Digital arteries
What structures are put at risk with penetrating injuries to the dorsum of the hand?
Extensor tendons
What extensor tendon injuries in the hand are treated and how?
More than 50% division
Surgical repair with splintage in extension for 6 weeks
What is mallet finger?
Avulsion of the extensor tendon from its insertion into the terminal phalanx and is caused by forced flexion of the extended DIPJ
How does mallet finger present?
Pain
Drooped finger
Inability to extend the DIPJ
What is the treatment for mallet finger?
A mallet splint holding the DIPJ extended which should be worn continuously for a minimum of 4 weeks
Which metacarpal fractures are treated conservatively?
3rd, 4th and 5th
How do fractures of the 5th metacarpal tend to occur?
A punching injury
What degree of flexion in a 5th metacarpal injury can be tolerated without affecting function?
45 degrees
Displacement of the 5th metacarpal in which plane should be fixed to avoid functional issues?
Rotational deformity
How are metacarpal fractures treated conservatively?
Neighbour strapping of the affected digit to the adjacent finger and early motion to maintain function
What treatment should be given in a fight-bite associated with metacarpal fracture?
Surgical washout of the wound to avoid septic arthritis
How are most phalangeal fractures managed?
Neighbour strapping
Splintage
How might intra-articular phalangeal fractures be fixed?
K-wires or small screws
How are significantly displaced or angulated phalangeal fractures managed?
Manipulation under anaesthetic
