Hand And Wrist Flashcards
Common hand and wrist problem
Nerve compression syndrome - carpal tunnel or cubital tunnel
Arthritis - OA and RA
Trauma - tendon injuries, chronic injuries
Hx or hand and wrist pain
Pain - is it specific to the wrist or is it generalised other joints affected
ONSET - rapid - trauma or slow - degenerative
Any other joint problems
Other systemic conditions - RA
Prev injury
Hand dominance
Jobs
Hobbies
Holistic approach - how it affects their whole life
What are the signs/ symptoms of a median nerve injury
Thenar eminence wasting
Sensory disturbance in the distribution of the lateral side of the hand (in the anatomical position )
Ulnar nerve lesion signs and symptoms
Claw hand - partial the little and ring finger
Sensory disturbance over the little finger
The total affects depend where the damage is if it in the elbow - cubital tunnel the arm will have some sensory pain and disturbance
If it is damaged a guy one canal multiple symptoms can be caused depending on where the damage is
Location Symptoms Associations
Zone 1 Proximal (prior to ulnar nerve bifurcation) Mixed motor & sensory Ganglia & hook of hammate fractures
Zone 2 Surrounding deep motor branch ulnar nerve Motor only Ganglia & hook of hammate fractures
Zone 3 Surrounding superficial sensory branch of ulnar nerve Sensory only Ulnar artery pathology
Radial nerve injury signs and symtoms
Wrist drop due to the inability to extend the wrist
Anatomical snuff box sensory disturbance
Injury can occur in the upper arm - fracture of the humerus usually the reason
Elbow - entrapped
Wrist - elbow deformity and soft tissue masses
Axilla - most common cause is compression
Dislocation at the head of humerus is possible as well - Saturday night palsy - crutch palsy
What to to determine about swelling of the wrist
Time frame - when did it start sudden or more gradual - getting worse
Is the swelling soft - soft tissue or oedema or is it hard - boney deformity
Diffuse
Single/multiple
Any other joint swellings
What muscles does the median nerve supply
L - lateral 2 lumbricals
O - opponents pollicis
A - abductor Pollicis
F - flexor Pollicis brevis
Some of these muscles make up the thenar eminence - OAF muscles
What muscles does the ulnar nerve supply
Hypothenar Medial 2 lumbricals Adductor Pollicis Palmer and dorsal interossei Palmar brevis Flexor carpii ulnaris Flexor digitorum profundus
Damage to what causes a complete claw hand
Median nerve and the ulnar nerve
OA of the thumb signs symp
May not be symptomatic
May have pain
Exam - axial grind
sign- shouldering of the CMC joint
Tx of OA of the thumb
Splint and analgesia Steroid injection Excision Arthrodiesis Replacement
Sign of OA of the DIP and PIP
DIP - heberdens nodes
PIP - Bouchards nodes
OA tx
Exercise weight loss Local muscle strengthening Heat and cooling therapies Electro therapy MEd - paracetamolNSAIDS Topical NSAIDS Topical capsaicin Steroid injections Joint surgery - arthroplasty fusion
RA hand and wrist
The sign are getting less frequent due to the management of RA with drugs - DMARDS and biological
1st line - DMARDS - methotrexate sulphasalazine, leflunomide
Bridging steroid
Biological- sarilumab
Then adalinumab, etanercept,infliximab, rituximab, abatacept
Combo in severe - DMARDS - methotrexate and a TNF inhibitor
Surgery can be for those who have deformities that are affecting function
What can RA lead to in the hand and wrist and how can these be dealt with surgically
Synovitis - cartilage destruction by pannus the inflammatory granulation tissue, tendon compression and rupture and nerve compression. Erosion and dislocation/ subluxation of the joint Tx - con - splint Surg - synovectomy Finger realignment End on transfer Joint fusion Joint replacement
Dupytrens contracture what is it
Fibrosis of longitudinal structures in the palmar fascia
Leading to contracture of the MCPJ and PIPJ leading the curling of the ring and little finger
What can dupytrens be associated with
Peyronies - penile fibrosis
Lederhosen - ball of the feet fibrosis
Risk factors for dupytrens
Northern Europe Chronic alcoholism Liver disease Smoking Diabetes Epilepsy / antiepileptics
Types of tx for a dupytrens
Inject collagenase - clostridium histolyticum
Percutaneous needle fasciotomy
Can have open where you move the affects palmar fascia and release the contractures
How to treat finger deformities such as swan neck, boutonierres, mallet finger
Splint
Corrective surgery
- fusion arthroplasty
What is trigger finger
Tendon nodules
- swelling for a flexor tendon or a tightening of the sheath
The tightening or swelling is proximal to the A1 pulley the nodule formation prevents the tendon gliding smoothly and instead ‘catches’ causing the finger to lock into flexion
As extension occurs the nodules moves with the flexor tendon by them becomes stuck n the proximal side of the pulley and the finger has to be flicked straight
TX of trigger finger
Simple rest or a splint
Injection - steroid
May need surgical release
What are ganglions
Smooth multilocular swelling or cysts they contin a jelly-like fluid that is in communication with joint capsules of tendon sheaths
Tx of ganglions
No treatment
Unless they cause mass effects or pain
Where they can then we spirited or excision - excision dec chance of recurrence
Complication after surg - painful scar, recurrence or NV damage
-bash with a bible
Can disappear spontaneously
What is de Quervains tenosynovitis
It is a stenosing tenosynovitis
There is tightening and thickening
Of the 1st extensor compartment
Abductor pollicis longus and the extensors pollicis brevi tendons at the border of the anatomical snuffbox as they cross the distal radial styloid
What test is for de quervains tenosynovitis
Finklesteins test
Where you put the thumb in the palm of the hand and close the finger - pronate and passively ulnar deviate
= pain
Cause of de quervains tenosynovitis
Unknown
Maybe overuse
Tx of de quervains
Rest/splint/ice/steroids
Corticosteroid injection
Decompress tendons surgically
Causes of carpal tunnel
I - idiopathic C - Cushing or Cole’s fracture R - RA A - acromegaly / amyloid M - myxoedema P- pregnancy S - sarcoid SLE
What is carpal tunnel
Median nerve compression at the carpal tunnel
- flexor retinaculum
Tests for carpal tunnel
Direct compression Tinnels Phalens Thenar wasting Sensory disturbance
Investigation carpal tunnel
Nerve conduction study
Tx carpal tunnel
Splint analgesia
Steroid injection
Surg - open arthroscopic carpal tunnel decompression
Open decompression
Symptoms carpal tunnel
Tingling pain of the thumb, index and half the middle finger
Pain worse at night
Dangle hand over bed or flick the hand provides some respite
Why is the lateral palmar sensation spared in carpal tunnel
Because the palmar cutaneous branch of the median nerve does not pass under the flexor retinaculum
Hand infections management
May need surgical drainage
