Hand Flashcards
Immediate treatment in AnE for perilunate dislocation
MAnipulation and reduction
Carpal tunnel release if median nerve compression
Needs definitive fixation
Origin of ulnar nerve?
Medial cords C8 - T1
Types of ulnar nerve palsy?
Wrist - Guyon Canal syndrome
Above wrist - Cubital tunnel syndrome, Tardy ulnar nerve palsy
Borders of Guyon’s Canal?
Medial = Pisiform
Lateral = Hook of hamate
Roof = Palmar carpal lig
Floor = Flexor retinaculum
Causes of Guyon’s canal syndrome?
Only the more common ones
Ganglion cyst compression [80% of nontraumatic causes]
Hypothenar hammer syndrome
Hook of hamate fracture
Symptoms of Guyon Canal syndrome?
Motor = Opponens Digiti Minimi
Dorsal Interosseous, Palmar interosseoust
Sensory = Palmar 1.5 medial digits
Froment sign, Wartenberg sign, ulnar claw
Borders of cubital tunnel?
Medial = olecranon
Lateral = Medial epicondyle
Roof = FCU
Floor = MCL
Location of cubital tunnel syndrome lesion?
Lesion at medial epicondyle of humerus
Symptoms of cubital tunnel syndrome?
Referred pain in forearm
Sensory loss in hand [UN dermatomes]
Muscle atrophy and weakness [UN myotomes]
Intrinsic muscle wasting - guttering
Slight clawing
Wartenberg’s sign
Etiology of Saturday night palsy?
Humeral shaft fracture
Prolonged RN compression along humerus
Symptoms of saturday night palsy?
Sensory: 1sst dorsal webspace
Motor:
Low - IPJ extension of thumb + MCPJ 2-5 extension
High - Wrist extension drop+ elbow drop
Source of Median Nerve?
Medial and lateral cords.
C5-T1
Tests in Median nerve lesion?
Clench fist & test power - Benedict hand
Ant Intero Nerve
Test FDS
Test FPL
Test FDP
Test APB (Carpal tunnel syndrome)
Special tests in Median Nerve lesion?
Tinel’s sign
Phalen’s sign
Durkan’s compression test
What relieves pain in carpal tunnel syndrome?
Shaking hand of hanging arm over side of the bed
What to take note of for diabetics in nerve injuries?
DM can cause peripheral nerves to be more sensitive to compression. Not all numbness in diabetics are peripheral neuropathy
Does Carpal tunnel syndrome have Benediction sign?
No. Only higher lesions like AIN
Common site of AIN entrapment?
Median nerve
Deep head of pronator teres
Conservative Mx of ganglion cysts?
Leave alone - favoured, resolve after months
Aspiration (50% recurs)
Rupture
OR CONSERVATIVE EXCISION
What are the hand tendinopathies?
Stenosing Tenosynovitis
De Quervain’s Tenosynovitis
Suppurative Tenosynovitis
What is Stenosing Tenosynovitis?
Tenosynovitis of flexor tendons at level of A1 pulley.
Diagnosed clinically
RF for Stenosing Tenosynovitis?
Women >50
Tendon overuse
PMH = DM, HypoT, Gout, RA, pregnancy, Acromegaly
Green classification for Trigger finger?
Grade 1 = Palm pain + tenderness at A1 pulley
2 = Catching of digit
3 = Locking of digit, passively correctable
4 = Fixed, locked digit
Presentation of Stenosing Tenosynovitis?
Clicking, catching and locking of digit - 엄지, 중지, 약지
Progressive pain over distal palm
FFD
What happens in Stenosing Tenosynovitis if A2, A4 pulley is involved instead of A1?
Bowstringing of the finger
What is DeQuervain’s Tenosynovitis?
Entrapment tendinitis of dorsal first extensor compartment affecting EPB & APL
The tendons run along the thumb side of the wrist and attach to the base of the thumb
Signs of DeQuervain’s Tenosynovitis in PE?
Swelling and palpable sheath thickening over course of tendons
Radial sided wrist pain, worse with Finkelstein maneuver (thumb extension)
What are Kanavel’s signs in suppurative tenosynovitis?
Pain on passive extension (earliest)
Fusiform swelling of finger
Digit held in flexion
Pain along distribution of flexor sheath
Signs of paronychia?
Nail fold tenderness
Fluctuance -> abscess
Nail bed motility -> tracking under nail
Chronic paronychia - nail plate hypertrophy, nail fold blunting/retraction, prominent transverse ridges
Conditions a/w Dupuytren’s contracture? DEAFEST PAIL
DM
Epilepsy
Age
Family Hx/fibromatoses
Epileptic meds
Smoking
Trauma/Manual labour
Peyronie’s disease
AIDS
Idiopathic
Liver disease
What is Dupuytren’s Contracture?
Nodular hypertrophy and contracture of palmar aponeurosis, causing tendons attached to finger to be unable to move properly
Hand manifestations of RA?
Bilaterally deforming arthropathy with MCPJ, PIPJ and DIPJ or all fingers
Swan neck - flexion of DIPJ, hyperextension of PIPJ
Boutonniere’s - Hyperextension of DIPJ, flexion of PIPJ
Mallet finger which tendon/muscle affected?
Disruption of terminal extensor tendon distal to DIP joint.
Diagnosed with distal phalanx about 45° of flexion with lack of active DIP extension
Median nerve supplies more in ____, almost all ____ except the medial few ones
Median nerve supplies more in arm, almost all flexors except medial few ones.
Ulnar nerve supplies more hands
Median nerve supplies the more ____ muscles in forearm
More superficial ones
Why is Extensor Carpi Radialis spared in finger drop of PIN palsy?
Cuz ECR supplied by more proximal part of radial nerve
What effect can RA have on extensor tendon in finger?
Tendon subluxation!!! RA pushes extensor tendon to the side = cant extend finger
McGowan’s classification of Cubital tunnel syndrome?
1 = sensory symptoms wo loss of two-point sensibility or muscular atrophy
2 = Sensory symptoms + weakness on pinch and grip without atrophy
3 = Sensory symptoms + atrophy and low intrinsic muscle strength
4 = profound muscle atrophy and sensory disturbance
Colles’ frac vs Smith’s frac?
Colles’ = Low-energy FOOSH in wrist extension
Smith’s = FOOSH in wrist flexion
Early complications of Colles and Smiths?
TFCC injury from RUJ subluxation
Associated scaphoid/ulnar head/ulnar styloid #
Carpal tunnel syndrome
Late complications of Colles and Smiths?
EPL tendon rupture
Malunion
Secondary OA
Stiffness
Complex regional pain syndrome
What is Barton’s #?
Smith’s # that enters radiocarpal joint resulting in ant subluxation of distal fragment carrying carpus with it.
What is Bennett’s #?
Partial intra-articular 1st MCP base #
w/wo proximal, dorsal, radial displacement
Mx - closed reduction and fixation/ORIF
What is Rolando’s fracture?
Intra-articular, comminuted 1st MCP base #
NO subluxation or dislocation
What is Gamekeeper’s thumb?
Avulsion # of attachment of ulnar collateral lig at MCP joint or thumb
Usually due to instability of ulnar collateral lig
Can cause valgus instability
What is PIN compression syndrome?
PIN from Radial nerve affects nerve supply of forearm extensor compt
Classify radial nerve palsy?
Elbow and below: PIN syndrome [only motor]
Wartenberg syndrome [only sensory]
Above elbow: Humeral shaft frac
Sat Night Palsy
Cause of PIN syndrome?
Trauma, space filling lesions, inflammation, iatrogenic
Basically just compression
Space filling lesions e.g. ganglion, lipoma etc
Common site of PIN entrapment in PIN syndrome?
Arcade of Frohse, where PIN pierces supinator nerve
most superior part of the superficial layer of supinator muscle
Tennis elbow a/w PIN syndrome
Motor presentation of PIN syndrome?
IPJ extension of thumb [EPL]
MCPJ 2-5 extension [ED]
Wrist extension preserved but radially deviated
Resisted supination will cause pain
Common site of nerve entrapment in Wartenberg syndrome?
Superficial Radial Nerve compressed by scissoring action of brachioradialis and ECRL tendons during forearm pronation
What condition is Wartenberg syndrome a/w?
DeQuervain’s disease in 20% - 50%
Boundaries of carpal tunnel?
Lat = Scaphoid + Trapezium
Medial = Pisiform + hook of Hamate
Roof = transverse
Contents of carpal tunnel?
FDP tendon
FDS tendon
FPL
Median nerve
Causes of Carpal Tunnel syndrome?
Some associated conditions?
Inflamed synovium
Space occupying lesions e.g. gout
A/w: DM, obesity, RA, HypoT, Pregnancy
Inflamed synovium is commonest idiopathic cause
Branches of Median Nerve after Carpal Tunnel?
Where do they lie?
Palmar digital branch
Recurrent motor branch
Palmar for palmar surface and fingertips
Recurrent for thenar muscles
PC branch lies at level of wrist flexion crease
What wasting seen on PE of Carpal tunnel syndrome?
Thenar eminence wasting
Branches of Median Nerve in forearm?
AIN
Palmar cutaneous nerve
AIN supplies deep muscles in anterior forearm
Presentation for AIN syndrome
Only motor!! No sensory
Thumb adducted [Ape hand]
Benediction sign
Brief description of Ganglion cyst?
Content: Glairy fluid (uncooked egg white colour and consistency)
2 types: simple and Compound
Common site of ganglion cysts?
Grow out of tissues surrounding synovial joints and tendon sheaths
What is Rolando fracture?
Completely intra-articular fracture of base of thumb
When do Dupuytren’s contractures commonly occur?
what age
50s-70s.
Males 2x more common.
AD inheritance
Compare muscular loss in CTS and High median nerve lesion?
High MN lesion = All flexors of 3.5 digits + OAF lost
CTS = Only Opponens Pollicis and APB gone
‘O’ = opponens, ‘A’ = abductor, ‘F’ = flexor
Thenar eminence lost in what lesion? Why?
Opponens, Abductor, Flexor muscle lesions.
They have big thenar eminence.
What is trigger finger?
Commonly presents with nodule at where?
Inhibition of smooth tendon gliding due to mechanical impingement at level of A1 pulley.
Nodule on palm in line with finger [at flexor tendon]
Mx of trigger finger?
Splinting
NSAIDs
Steroids injections
Surgical release
Mx of DeQuervain’s Tenosynovitis?
Conservative = thumb spica braces, injections
In Refractory cases = 1st dorsal compartment surgical release
What conditions predispose to DeQuervain’s Tenosynovitis?
RA
HyperT
Pregnancy etc etc
When to take XR post-fracture in Smith’s or Colle’s?
7-10 days. Ensure frac is not slipped, even when plate is used.
