Hand Flashcards
What is the classification of trigger finger (stenosing tenovaginitis)
Green classification
Stages
I: pre-triggering: pain along flexor tendon but no demonstrable triggering
II: triggering: catch but can actively extend
III: triggering and locking
a: req active extension
b: req active flexion
IV: contracture: fixed flexion contracture of PIPJ
What is the mgx of trigger finger
Conservative
- lifestyle: avoid trauma
- occupational therapy: splint PIPJ in 15deg/ physioT
H&L injections (triamcinolone and lignocaine)
Op:
- division of A1 pulley in the midline (tendon sheath)
What are the kanavel signs
infectious tenosynovitis of flexor tendon sheath in hand
o Slight flexed position of affected finger
o Fusiform swelling over affected tendon
o Tenderness on percussion along tendon sheath
o Tenderness on extension of affected finger
what are the zones of the hand
o Zone 1: FDP o Zone 2: FDP and FDS (‘No man’s land as healing is poor) o Zone 3: Palm o Zone 4: Carpal tunnel o Zone 5: Forearm
principles of tx of infected hand
- antibiotics: flucloxacillin/ cephalosporin
- rest and elevation: sling, roller towel
- analgesia
- drainage
- send pus for microb investigation
- splintage (where ligaments are in greatest length - reduce likelihood of stiffness)
- physiotherapy
what are the 5 tissues of the hand
- skin and subcutaneous tissue
- muscle and tendon
- blood vessels
- nerves
- bones and joints
Ulnar nerve examination
- look
- test
Look:
- claw hand
- wasting of the first dorsal interosseous, guttering
Test:
- abduction of index finger (1st dorsal interosseous)
- adduction (cross first 2 fingers)
- FDP of little finger
- froment sign (adductor policis)
- sensation to little finger and hypothenar eminence
What does the ulnar nerve supply
Motor: thenar muscles except LOAF
- hypothenal (ODM, AbDM, FDM)
- 3rd/4th lumbricals
- dorsal and palmar interossei
- adductor pollicis
forearm: FCU, radial half of FDP
Sensory: innervate anterior and posterior surfaces of the medial 1 Half fingers and its associated palm area
Localising site of injury in ulnar n lesions
Elbow: FDP and sensation to hypothenar lost
wrist: above is preserved
Differentials of ulnar n palsy
- carrying angle of elbow
- lacerations over medial aspect of elbow
- thickened ulnar nerve
- ulnar n subluxation
Median n examination
Look: wasting of thenar eminence Test: - FPB (abducting thumb) - ok sign (FDP and FPL) - flexion of PIPJ (FDS) Special: - tinel and phalen at carpal tunnel
Localisation in medial n palsy
carpal tunnel:
- spare thenar sensation, FDP, FPL, FDS
- affects FPB
AIN lesion:
- hits FDP, FPL
High lesion:
affects all
What does the median nerve supply
Motor:
- flextors in forearm less FCU and ulnar 2 FDP: pronator teres, FCR, palmaris longus, FDS, lat 2 FDP, FPL, PQ
- LOAF: lumbricals 1,2 and thenar muscles
Sensory
- palmar: thenar eminence + 3half fingers
- volar: tips of 3half fingers
Radial nerve examination
Look: finger drop/ wrist drop Test: - EPL (retropulsion of thumb) - extension of fingers (ED) - extension of wrist (ECR, ECU) - extension of elbow (triceps brachii) - sensation over first webspace
Localisation of radial nerve lesion
PIN:
- finger drop (no wrist drop)
- no sensory loss
Spiral groove:
- wrist drop
- sensory loss
What does the radial nerve supply
Sensory: posterior forearm, dorsal hand
Motor:
- triceps brachii
- extensor muscles in forearm
how many dorsal components does the hand hand and their contents
1st: APL, EPB
2nd: ECRL, ECRB
3rd: EPL
4th EDC + Ex indicis
5th EDM
6th ECU
What is a ganglion and
Common sites for ganglions
Ganglion: fluid filled outpouching of the synovial mb of a joint or tendon sheath
Usually found over dorsal or palmar radial side of wrist, over flexor sheaths and over DIPK
PVNS
- what is it
- how to diagnose
- types and where to find
- features
- tx
benign proliferative disorder of synovial lining of joint, bursa, tendon sheaths > inflammation and nodular thickening of synovial mb
histo diagnosis (giant cell seen)
Types
- diffuse: knee>hip>ankle>shoulder
- localised: hands/ feet (volar aspect of DIPJ)
- firm, not transilluminable, non tender
TX: synovectomy
RA features of the hand
Elbow: swelling, subluxation of radius
Wrist: carput ulnae syndrome, swelling
MPJ: ulnar deviation, swelling, volar subluxation
Fingers: boutonneire/ swan neck
Thumb: CMC swelling/ subluxation, z deformity
OA features of hand
PIP: radial/ulnar dev, Bouchard nodes
DIP: heberden nodes, mucous cyst, mallet deformities, deviation
Thumb:
- swelling/ subluxation of CMC jt, grind test positive
active vs passive ROM limitation
active < passive:
- muscle weakness/ nerve palsy
- tendon rupture
- tendon adhesion
Passive limited
- joint contracture
Allen test
- what does it test
- how to test
- significance
Test patency of palmar arch (communication between radial and ulnar artery)
- test arterial blood flow
- elevate hand, clench fist for 30 sec
- occlude ulnar and radial arteries
- open hand
- release ulnar pressure. maintain radial pressure. time length req for colour to return (n=5-15sec)
if time increased: ulnar artery supply insufficient. may not be safe to cannulate/ needle radial artery
DeQuervain tenosynovitis
- what tendons involved
- RF
- how to test
- mgx
first dorsal comp: EPB, AbPL
RF: clothes wringing, pruning, cutting with scissors
Finkelstein test
Mgx: Conservative - lifestyle: rest - occupational: thumb spica - physioT: ultrasound - meds: NSAIDS H&L Sx: decompression of 1st compartment (tendon sheath release)
Differentials for lump in hand
Cystic/ soft: ganglion, lipoma, vascular
Firm: PVNS, Neuroma, Fibroma
Hard: osteochondroma, bone tumor
differentials for painful wrist
Referred: cervical spondylosis
Joint: OA, RA, infection
Periarticular: dequervain, tenosynovitis, instability
differentials for painful hand
Referred: neck, shoulder, mediastinum
Joint: OA, RA
Periarticular: carpal tunnel, tenosynovitis, infection
What to look for in a lateral hand/wrist x ray
alignment of bones - cup in cup
3rd metacarpal - capitate - lunate -radius in one straight line
What are the carpal bones
Scaphoid Lunate Triquetrium Pisiform
Trapezium Trapezoid Capitate Hamate
what is Kienbock disease
AVN of lunate
Contraindications for H&L
plantar fasciitis and archilles tendonitis
SE of H&L
- hypo pigmentation of skin
- depression in skin (lipoatrophy)
- infx
- tendon rupture
- nerve injury
What is wallerian degeneration
degeneration of axons distal to site of transection (resorbed by phagocytes)
What is sedon classification
Peripheral n injury classification
Seddon
- neuropraxia (mildest, segmental demyelination, axonal continuity preserved, affects motor > sensory > autonomic)
- axonotmesis (loss in continuity of axon and covering myelin but preserve connective tissue framework of nerve)
- neurotmesis (destruction of endoneural tubes) > better to use Sunderland
What is Sunderland system
1st deg: neuropraxia (segmental demyelination) 2nd deg: axonotmesis (axon disruption) 3rd deg: 2+endoneurium 4th deg: 3+perineurium 5th deg: 4+epineurium
Why is there thenar eminence sparing in carpal tunnel syndrome
palmar cutaneous branch to thenar eminence given off before carpal tunnel
What does the Anterior interosseous nerve supply
FPL
PQuadratus
radial 1/2 FDP
no sensory loss!
What does the median nerve proper supply
FDS pronator teres FCR palmaris longus L1, L2
Features of high median n lesion (e.g. pronator teres syndrome)
benediction sign
posture: loss of thumb abductoin
wasting: flexor pronator mass, thenar eminence
motor:
- paralysis of long flexors to thumb, index, middle (FDS and FDP)
- intrinsics: loss of opposition and abduction of thumb
Sensory
- loss of lateral 3.5
what are the thenar muscles
opponens pollicis
abductor pollicis brevis
flexor pollicis brevis
Anatomical boundaries of carpal tunnel and its contents
radial side: scaphoid and trapezium
ulnar side: pisiform + hook of hamate
volar: flexor retinaculum
content:
- FDP (4)
- FDS (4)
- FPL
- median nerve
Causes of carpal tunnel syndrome
- idiopathic
- anat abnormalities
> bone: wrist #, acromegaly
> ST: lipoma, ganglia - physio
> fluid imbalances: pregnancy, menopause, cardiac/ renal failure, obesity
> inflam: RA
> prev trauma
> met: Gout
> neuro: DM, alcoholism
> endo: hypothyroidism, acromegaly
Mgx of carpal tunnel syndrome
Conservative
- lifestyle modification: reduce repetitive activity
- occupational therapy (splint wrist)
- vit B complex
- NSAIDs
- H&L injection
SX: carpal tunnel release
Explain the ulnar paradox
lower the lesion, the worse the clawing
high lesion: medial half FDP not working - less claw
low lesions: FDP contributes to flexion
Explain the claw hand
hyperextension of MCP of little and ring fingers, flexion of IPJ
- unopposed FDS and FDP
- loss of 3rd and 4th lumbrical + interossei fx: normally flex MCP and extend IPJs
- median and index finger normal: lateral lumbricals supplied by median nerve
Explain wartenberg sign
ulnar deviation of little finger in extension due to unopposed action of extensor digiti minimi (insertion is slightly medial)
adduction ability of intrinsics lost
what is ulnar tunnel syndrome
- differentiator from cubital tunnel syndrome
compression of ulnar n as it passes through Guyon canal
- preserved strength of wrist and 4/5th digit flexors
Causes of cubital tunnel syndrome
and mgx
- constriction by fascial bands
- subluxation of ulnar nerve over medial epicondyle
- cubitus valgus
- bony spurs
- tumors, ganglion
- repetitive elbow flexion and extension
mgx:
- simple decompression
- medial epicondylectomy
- anterior transposition of ulnar n
- steroid injection
What does the PIN supply
extensor digitorum, digiti minimi, carpi ulnaris, pollicis brevis, pollicis longus, indicis, abductor pollicis longus
Which muscles control wrist extension
ECRL, ECRB, ECU
What is a waiter tip deformity
from Erb’s palsy (C5,6,7)
- shoulder int rotated
- elbow extended
- wrist flexed and pronated
Duputren contracture
- what
- associations
- mgx
nodular hypertrophy and contracture of palmar aponeurosis
DEAFEST PAIL: DM, epilepsy, age, family history, epileptic med (phenobarbitone), Smoking, Trauma, Peyronie disease, AIDs, idiopathic, liver disease (alcohol)
mild: modifying tools
mod: intralesional glucorticoid injectin with triamcinolone and lidocaine
severe: surgery
- fasciotomy
- partial fasciectomy w z-plasty
- dermo fasciectomy
- arthrodesis, amputation
Differentials for radial sided wrist pain
- intersection syndrome
- de quervain
- wartenberg syndrome (sup br of radial n compression)
- scaphoid #
- scapholunate instability
- 1st CMC jt OA
RF of trigger finger
overuse/ local trauma
DM
RA
gout
complications of wrist #
common: poor grip strength, stiffness, radial shortening
Early: - difficult reduction/ loss of reduction - compartment syndrome - EPL rupture - acute carpal tunnel syndrome Late: - malunion - painful wrist from ulnar prominence - frozen shoulder - post traumatic arthritis - carpal tunnel syndrome - reflex sympathetic dystrophy
Scaphoid #
- intra or extra articular?
- x rays to order
ALWAYS intra-articular
X rays: AP, lat, scaphoid view, 2 oblique (semi pronate, semi supinated)
Mgx of scaphoid #
- initial (# not seen)
- displaced (acute vs non union)
- cx
initial: scaphoid plaster and sling in glass holding position (hand pronate, wrist dorsi, radial dev, thumb forward)
displaced #: ORIF with scaphoid compression screw
acute: percutaneous fixation, arthroscopy
non union: open fixation with bone grafting
cx: AVN, non union, OA
Non traumatic causes of ulnar claw hand
- compression of ulnar nerve at cubital tunnel
- osteophytes in OA elbow
- ganglion cyst in cubital tunnel
- inflammation and edema from RA of elbow
- ext compression prolonged - lean elbow on bike handle - stretching/ irritation of ulnar nerve at cubital tunnel
- cubital valgus (malunion of lateral condylar #)
- repeated subluxation
What is the mgx of mallet finger deformity and for how long
Conservative
- immobilisation in mallet splint
- analgesia
- rest, ice, elevate
Sx if
- bony mallet >2/3 of joint
- unstable #
- non union
NUH: 6w whole day + 6 w at night
what to think of for ganglion at DIPJ
called a mucocyst
a/w with OA of underlying joint
ultrasound findings of ganglion
well defined margins, thick walls, appears anechoic
