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Ortho and Rheum > Hand and wrist > Flashcards

Hand and wrist Flashcards

1
Q

What are the carpal bones?

A

Scaphoid (proximal row, base of thumb), Lunate, Triquetrium, Pisaform, Trapezium (distal row base of thumb), Trapezoid, Capitate, Hamate

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2
Q

What is flexor tenosynovitis

A

Inflammation of synovial sheath of finger flexor tendons, leads to volar swelling and tenderness just distal to wrist, palm and fingers may also be affected

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3
Q

Symptoms of flexor tenosynovitis

A

Hand feels stiff, swollen and painful, especially in the morning
Volar swelling and tenderness
Rest helps

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4
Q

Management of flexor tenosynovitis

A

Rest

Injection is sometimes needed - in the palm usually

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5
Q

What causes flexor tenosynovitis?

A

Caused by unaccustomed or repetitive use of finger and inflammatory arthritis

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6
Q

What is Carpal tunnel syndrome?

A

Median nerve entrapment in the carpal tunnel at the wrist - often caused by flexor tenosynovitis

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7
Q

What increases risk of carpal tunnel syndrome? x5

A 
Repetitive use of hand - flexor tenosynovitis
3rd trimester pregnancy 
Amyloidosis (rare)
Myxoedema (rare)
Ganglion
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8
Q

Symptoms of carpal tunnel syndrome?

A

Pain, tingling and numbness in median nerve distribution (thumb to radial side of ring finger)
May wake at night and need to shake to relieve it
Can get intense aching in the arm
Can get permanent numbness and wasting of thenar eminence

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9
Q

Diagnostic tests for carpal tunnel syndrome?

A

Tinel’s (tapping median nerve in CT)

Phalen’s (holding wrist in forced dorsiflexion)

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10
Q

Management of CTS

A

Splint at night
Corticosteroid injections
If daytime symptoms etc not getting better - nerve-conduction studies - if slowed conduction, suggestive of demyelination - decompression surgery

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11
Q

What can happen post-operatively in CTS decompression surgery ?

A

Pins and needles often worsen briefly as nerve recovers

Recovery of sensation and strength can be limited if serious damage was done

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12
Q

What is finger flexor tendonosis?

A

Palpable thickening and nodularity of the finger flexor tendon - due to gripping and hard manual work

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13
Q

Symptoms of finger flexor tendonosis?

A

Affected fingers are stiff in the morning - pain in the palm and along dorsum of the finger
Pain can be reproduced by passive extension of the finger

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14
Q

When is finger flexor tendonosis common?

A

In rheumatoid arthritis

and in dactylitis in seronegative arthritis

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15
Q

What is trigger finger?

A

Caused by a nodule catching at the pulley over the MCP joint
Patient wakes with finger flexed and forces it straight with painful/painless click
Triggering can also occur after gripping

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16
Q

Management of finger flexor tendonosis?

A

Steroid into tendon nodule can help

Surgical release may be needed

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17
Q

What is De Quervain’s tenosynovitis?

A

Affects the tendon sheath of abductor pollicis longus and extensor pollicis brevis at radial styloid

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18
Q

Symptoms of De Quervain’s tenosynovitis?

A

Tenderness and swelling at radial styloid (rather than OA at base of thumb)

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19
Q

Diagnostic test for De Quervain’s tenosynovitis?

A

Finkelstein’s test

Pushing thumb into palm with grip and hand held in ulnar deviation - increases pain

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20
Q

Management of De Quervain’s tenosynovitis?

A

Rest essential
Avoid using thumb in extension and pinching
Local anti-inflam gels
Injection of steroids rapidly relieves pain
Surgery rarely needed

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21
Q

Difference between extensor and wrist synovitis?

A

Extensor synovitis is back of the hand - hourglass shape proximal and distal to the wrist due to extensor retinaculum

Wrist synovitis is diffuse swelling distal to radius and ulnar

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22
Q

What causes extensor synovitis?

A

Repetitive wrist and finger movements, especially with wrist in dorsiflexion - aka keyboard workers

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23
Q

What is mallet finger?

A

Flexion deformity affecting distal IPJ - due to distal extensor tendon rupture or avulsion - painless weakness with inability to actively extend the fingertip

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24
Q

What causes mallet finger?

A

Normally occurs following traumatic forced flexion of extended fingertip - eg. ball

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25
Q

Joints affect in nodal OA

A

Distal IPJ - get swelling and inflammation, pain subsides and left with bony swellings (Heberden’s nodes)
Can also affect proximal IPJ - Bouchard’s nodes (less common)

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26
Q

Consequence of nodal OA

A

Prognosis is good therefore often just manage with anti-inflam gels
Appearance can be distressing
Can limit pinch gripping

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27
Q

What is Dupuytrens contracture?

A

Painless common condition - palpable fibrosis of palmar aponeurosis - usually in palm, occasionally at base of digit

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28
Q

In who is Dupuytrens contracture more common? x5

A

White people, men, heavy drinkers, smokers, DM patients

29
Q

Pathology of Dupuytrens contracture?

A

Fibroblast proliferation first in superficial fascia and then invades the dermis

30
Q

What can Dupuytrens contracture lead to?

A

Often flexion of digit(s), most often the ring finger

No pain - it is function that is the problem

31
Q

Where else can nodular fibromatosis affect? x3

A

Sole of the foot
Knuckle pads - extensor surface (Garrods pads)
Penis (Peyronies disease)

32
Q

Management of Dupuytrens contracture and nodular fibromatosis

A

Splints if earlier on
Role of local corticosteroid injections is unknown
Surgical excision is helpful but recurrence is common

33
Q

What is cubital tunnel syndrome?

A

Ulnar nerve compression at the elbow caused by direct pressure from leaning, stretching the nerve with prolonged flexion at night or holding a telephone

34
Q

Symptoms of cubital tunnel syndrome?

A

Pins and needles in ulnar distribution - prolonged can cause hypothenar wasting and weakness of intrinsic hand muscles

35
Q

Diagnostic test of cubital tunnel syndrome?

A

nerve is tender and sensitive at elbow and there is positive tinels sign

36
Q

Where else other than cubital tunnel can ulnar nerve be compressed

A

Guyons canal at wrist

37
Q

Joints affected in hand in RA

A

MCP and proximal IPJ and wrists

38
Q

What can be affected in psoriatic arthritis

A

Distal IPJ with adjacent nails affected

39
Q

Cause of sudden wrist inflammation in older patients

A

Acute pseudogout (urate gout rarely affects the hands) - due to calcium pyrophosphate arthritis

40
Q

Treatment of hand pseudogout

A

Steroid injections of short course of NSAIDs or colchine

41
Q

What can develop in the hands in diabetics?

A

Diabetic stiff hand (cheiroarthropathy - limited joint mobility syndrome)

42
Q

Frequency of diabetic stiff hand?

A

Seen in 5-10% of patients with T1 diabetes - mostly in poor control

43
Q

What happens in diabetic stiff hand?

A

Patients develop tight, waxy skin

44
Q

Sign of diabetic stiff hand?

A

Positive prayer sign

Cannot hold fingers and palms together in prayer sign

45
Q

What is associated with diabetic stiff hand? x3

A

Limited shoulder mobility, diabetic nephropathy and retinopathy

46
Q

What happens in Raynauds syndrome?

A

When cold, severe vasospasm causes very sharply demarcated pallor of digits (one or more), as circulation returns - digit becomes blue and then bright red due to reactive hyperaemia

47
Q

What is a ganglion?

A

A cystic swelling in continuity with joint or tendon sheath through a fault in the capsule

48
Q

What is in a ganglion?

A

Filled with a clear, viscous fluid rich in hylauronan

49
Q

Management of ganglion

A

Common on dorsal wrist and resolve spontaneously
Aspiration and injection are rarely effective
If persistent and painful then can do surgical excision

50
Q

Important DDX of acute pseudogout in the hand/wrist?

A

Septic arthritis

But RARE

51
Q

What steroid is used for local injections?

A

Hydrocortisone acetate or methylprednisolone (5x as powerful)

52
Q

What is Boutonniere deformity

A

Rupture of central slip of extensor tendon - allows lateral bands of extensor mechanisms to slip towards the palm - become flexors of PIP joint
Therefore flexion at PIP and hyperextension at DIP joint

53
Q

What causes Boutonniere deformity

A

Can occur following injury (forced flexion of extended PIP joint) or secondary to RA

54
Q

Treatment of Boutonniere deformity

A

Splinting PIP in complete and constant extension - movement allowed at DIP and MCP joints

55
Q

Symptoms of Achilles tendon rupture

A

Sudden pain or ‘kick’ at back of ankle during running or jumping as tendon ruptures
Can walk with a limp and slight plantar flexion remains but cannot raise heel from floor when standing on affected leg (calf raise)

56
Q

What is the squeeze test?

A

Simmonds test for achilles tendon rupture
Patient kneels on chair
Squeeze both calves
If achilles tendon is ruptured then there is less plantar flexion on the affected side

57
Q

Treatment of achilles tendon rupture

A 
Tendon repair is preferred by young athletic patients 
Conservative management (eg. casting) may be better in smokers, diabetics and >50 years old
58
Q

Where does posterior interosseous nerve compression occur?

A

Branch is compressed on passing through proximal supinator muscle eg. after forearm fracture or excessive exercise

59
Q

Symptoms of PION compression

A

Weakness of thumb and finger extension

60
Q

Where does AION compression occur?

A

Compressed under fibrous origin of flexor digitorum profundus

61
Q

What does AION compression cause?

A

Weakness of pinch and pain along forearms radial border

Patient will be unable to flex DIP joint of index finger and PIP joint of the thumb to make O shape

62
Q

Where does common peroneal compression occur?

A

Against head of fibula eg. with plaster casts or proximal fibular fracture

63
Q

What does common peroneal compression cause?

A

Inability to dorsiflex the foot

Reduced sensation over the dorsum of the foot

64
Q

Investigations in CT syndrome

A

Nerve conduction studies

65
Q

Management of CT syndrome in pregnant lady

A

Splint as its only a temporary condition

66
Q

Most important ligament in MCP thumb joint

A

Beak ligament

67
Q

What is shoulder thumb

A

Deformity leading to z shaped thumb - boutinniere deformity - at first MCP joint

68
Q

Rheumatoid hand treatment

A

Rest, analgesia, steroids - disease modifying drugs

Ortho and Rheum (13 decks)

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