Hand and wrist Flashcards
What are the carpal bones?
Scaphoid (proximal row, base of thumb), Lunate, Triquetrium, Pisaform, Trapezium (distal row base of thumb), Trapezoid, Capitate, Hamate
What is flexor tenosynovitis
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
Symptoms of flexor tenosynovitis
Hand feels stiff, swollen and painful, especially in the morning
Volar swelling and tenderness
Rest helps
Management of flexor tenosynovitis
Rest
Injection is sometimes needed - in the palm usually
What causes flexor tenosynovitis?
Caused by unaccustomed or repetitive use of finger and inflammatory arthritis
What is Carpal tunnel syndrome?
Median nerve entrapment in the carpal tunnel at the wrist - often caused by flexor tenosynovitis
What increases risk of carpal tunnel syndrome? x5
Repetitive use of hand - flexor tenosynovitis 3rd trimester pregnancy Amyloidosis (rare) Myxoedema (rare) Ganglion
Symptoms of carpal tunnel syndrome?
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
Diagnostic tests for carpal tunnel syndrome?
Tinel’s (tapping median nerve in CT)
Phalen’s (holding wrist in forced dorsiflexion)
Management of CTS
Splint at night
Corticosteroid injections
If daytime symptoms etc not getting better - nerve-conduction studies - if slowed conduction, suggestive of demyelination - decompression surgery
What can happen post-operatively in CTS decompression surgery ?
Pins and needles often worsen briefly as nerve recovers
Recovery of sensation and strength can be limited if serious damage was done
What is finger flexor tendonosis?
Palpable thickening and nodularity of the finger flexor tendon - due to gripping and hard manual work
Symptoms of finger flexor tendonosis?
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
When is finger flexor tendonosis common?
In rheumatoid arthritis
and in dactylitis in seronegative arthritis
What is trigger finger?
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
Management of finger flexor tendonosis?
Steroid into tendon nodule can help
Surgical release may be needed
What is De Quervain’s tenosynovitis?
Affects the tendon sheath of abductor pollicis longus and extensor pollicis brevis at radial styloid
Symptoms of De Quervain’s tenosynovitis?
Tenderness and swelling at radial styloid (rather than OA at base of thumb)
Diagnostic test for De Quervain’s tenosynovitis?
Finkelstein’s test
Pushing thumb into palm with grip and hand held in ulnar deviation - increases pain
Management of De Quervain’s tenosynovitis?
Rest essential
Avoid using thumb in extension and pinching
Local anti-inflam gels
Injection of steroids rapidly relieves pain
Surgery rarely needed
Difference between extensor and wrist synovitis?
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
What causes extensor synovitis?
Repetitive wrist and finger movements, especially with wrist in dorsiflexion - aka keyboard workers
What is mallet finger?
Flexion deformity affecting distal IPJ - due to distal extensor tendon rupture or avulsion - painless weakness with inability to actively extend the fingertip
What causes mallet finger?
Normally occurs following traumatic forced flexion of extended fingertip - eg. ball
Joints affect in nodal OA
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)
Consequence of nodal OA
Prognosis is good therefore often just manage with anti-inflam gels
Appearance can be distressing
Can limit pinch gripping
What is Dupuytrens contracture?
Painless common condition - palpable fibrosis of palmar aponeurosis - usually in palm, occasionally at base of digit
In who is Dupuytrens contracture more common? x5
White people, men, heavy drinkers, smokers, DM patients
Pathology of Dupuytrens contracture?
Fibroblast proliferation first in superficial fascia and then invades the dermis
What can Dupuytrens contracture lead to?
Often flexion of digit(s), most often the ring finger
No pain - it is function that is the problem
Where else can nodular fibromatosis affect? x3
Sole of the foot
Knuckle pads - extensor surface (Garrods pads)
Penis (Peyronies disease)
Management of Dupuytrens contracture and nodular fibromatosis
Splints if earlier on
Role of local corticosteroid injections is unknown
Surgical excision is helpful but recurrence is common
What is cubital tunnel syndrome?
Ulnar nerve compression at the elbow caused by direct pressure from leaning, stretching the nerve with prolonged flexion at night or holding a telephone
Symptoms of cubital tunnel syndrome?
Pins and needles in ulnar distribution - prolonged can cause hypothenar wasting and weakness of intrinsic hand muscles
Diagnostic test of cubital tunnel syndrome?
nerve is tender and sensitive at elbow and there is positive tinels sign
Where else other than cubital tunnel can ulnar nerve be compressed
Guyons canal at wrist
Joints affected in hand in RA
MCP and proximal IPJ and wrists
What can be affected in psoriatic arthritis
Distal IPJ with adjacent nails affected
Cause of sudden wrist inflammation in older patients
Acute pseudogout (urate gout rarely affects the hands) - due to calcium pyrophosphate arthritis
Treatment of hand pseudogout
Steroid injections of short course of NSAIDs or colchine
What can develop in the hands in diabetics?
Diabetic stiff hand (cheiroarthropathy - limited joint mobility syndrome)
Frequency of diabetic stiff hand?
Seen in 5-10% of patients with T1 diabetes - mostly in poor control
What happens in diabetic stiff hand?
Patients develop tight, waxy skin
Sign of diabetic stiff hand?
Positive prayer sign
Cannot hold fingers and palms together in prayer sign
What is associated with diabetic stiff hand? x3
Limited shoulder mobility, diabetic nephropathy and retinopathy
What happens in Raynauds syndrome?
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
What is a ganglion?
A cystic swelling in continuity with joint or tendon sheath through a fault in the capsule
What is in a ganglion?
Filled with a clear, viscous fluid rich in hylauronan
Management of ganglion
Common on dorsal wrist and resolve spontaneously
Aspiration and injection are rarely effective
If persistent and painful then can do surgical excision
Important DDX of acute pseudogout in the hand/wrist?
Septic arthritis
But RARE
What steroid is used for local injections?
Hydrocortisone acetate or methylprednisolone (5x as powerful)
What is Boutonniere deformity
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
What causes Boutonniere deformity
Can occur following injury (forced flexion of extended PIP joint) or secondary to RA
Treatment of Boutonniere deformity
Splinting PIP in complete and constant extension - movement allowed at DIP and MCP joints
Symptoms of Achilles tendon rupture
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)
What is the squeeze test?
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
Treatment of achilles tendon rupture
Tendon repair is preferred by young athletic patients Conservative management (eg. casting) may be better in smokers, diabetics and >50 years old
Where does posterior interosseous nerve compression occur?
Branch is compressed on passing through proximal supinator muscle eg. after forearm fracture or excessive exercise
Symptoms of PION compression
Weakness of thumb and finger extension
Where does AION compression occur?
Compressed under fibrous origin of flexor digitorum profundus
What does AION compression cause?
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
Where does common peroneal compression occur?
Against head of fibula eg. with plaster casts or proximal fibular fracture
What does common peroneal compression cause?
Inability to dorsiflex the foot
Reduced sensation over the dorsum of the foot
Investigations in CT syndrome
Nerve conduction studies
Management of CT syndrome in pregnant lady
Splint as its only a temporary condition
Most important ligament in MCP thumb joint
Beak ligament
What is shoulder thumb
Deformity leading to z shaped thumb - boutinniere deformity - at first MCP joint
Rheumatoid hand treatment
Rest, analgesia, steroids - disease modifying drugs
