Hand and Wrist disorders Flashcards
common presentatjions in hand and wrist disordrs 5
tingling finfers
sticking fingers
stuck fingers
radial sided wrist pain
lumps and bumps
differential diagnosis for tingling fingers 3
peripehral nerve entrapment
-carpal tunnel and cubital tunnel syndrome
central nerve entrapment
peripheral neuropathy
key features of peripheral nerve entrapment 3
pain/ paraesthesia in the distribution of the nerve
altered sensation in the distribution of the nerve
reduced muscle function supplied by the nerve
what forms the carpal tunnerl
bones of the carpus roofed by the transverse carpal ligament (flexor retinaculum)
what structuers pass through the carpal tunnel 4
median nerve
4xFDS(flexor digitorum superficiallis)
4xFDP (flexor digitorm profundus)
FPL- flexor pollicis longus
associtaed conditions with carpal tunnel syndrome 8
usually idopathic
DM
hypothyroidis
RA
acromegaly
wrist fractures
pregnnacy
use of heavy vibrating machinery
presentation of carpal tunnel syndrome 5
nocturnal waking with tingling in thumb, index and middle finger
-releived by shaking hand
altered/reduced sensation in median nerve distribution
difficulty manipulating small objects
clumsiness
clinical signs of carpal tunnel syndrome 6
reduced sensation in median nerve distribution
reduced sensation on raidal side compared with ulna side
reduced thumb abduction
thenar muscle wasting
+ve tinels sign
+ve phalens test
management of carpal tunnel syndrome 3
wrist splints- esp noctural
steroid injections- esp during pregnancy
carpal tunnel decompression surgery
describe carpal tunnel syndrome surgery 2
Local anaesthetic w tourniquet
diveide flexor retinaculum longitudinally
anatomy of cubital tunnel
formed by cubital tunnel retinaculum
-ulnar nerve travels between the 2 heads of FCU (flexor carpi ulnaris) under the CTR
where does cubital tunnel syndrome take place
compression of ulnar nerve in cubital tunnel behind medial epicondyle of elbow
presentation of cubital tunnel syndrome 2
noctural waking with tingling
-in ulnar nerve distribution
-pinky and half of ring finger
altered/reduced sensation
clinical signs of cubital tunnel syndrome 7
relative loss of senaation
reduced sensation of unla side compared with radial side
reduced finger abduction
claw posture- if severe
hypothenar wasting
interosseus wasting
+ve tinels sign at elbow
management of cubital tunnel syndrome 3
soft elbow spint- for noctural syx
NOT steroid injection-risk of injuring nerve
cubital tunnel decompresion surgery
differenital diagnossi for sitcking fingers 2
trigger finger
extensor tendon subluxation
what causes trigger finger
constirction and thickening of the A1 pulley
what can be foundin trigger finger disease
nodule on tendon
clinical presenation of trigger finger 2
finger sticks in felxion then clicks painfully as finger is extended
syx worse in am
*-increased risk w diabetes and more difficult to treat
management of trigger finger 3
non-operative
-splintage
-steroid injection
operative
-surgical release/widening of A1 pulley
another name for trigger finger
flexor tensynovitis
associated conditions with trigger finger 2
DM
RA
differentials for stuck fingers 2
dupuytrens dissae
radial nerve or posterio interosseus nerve palsy
who gets Dupuytren’s disease 4
2:1 M:F
AD w variable penetrace
caucasion
men>55 women>65
which fingers are affected by Dupuytren’s disease 2
commonly ring and little finger
pathophys of Dupuytren’s disease
prolieratiion of myofibroblasts in palmar fascia producing pathological nodules and cords
associated conditions with Dupuytren’s disease 5
diabetes
epilepsy
alcohol
anti-convulsatns
FHx
clinical presenation of Dupuytren’s disease 1
fixed flexion deformities of MCP and PIP joints
difficulty with activities of daily living (ADLs)
-cant put hand in pocket
-poke themselves in eye when washing face
management of Dupuytren’s disease 4
needle aponeurecomty
collagenase injfections
fasciecotmy
dermofasciectomy
describe needle aponeurectomy in Dupuytren’s disease
under Local A
hypodermic needle used to cut cords
describe collagenase injfection in Dupuytren’s disease
injection of enzyme into cords
-digests collagen and weakens cord
-allows cord to be snapped by firm extension of finger 24-72hrs later
describe fasciectomy and dermofasciectomy
fasiectomy
-surgical excision of the cords
dermofasciectomy
-surgical excision of cords and overlying skin then application of a full thickness skin graft
most common lump in hand
ganglions
common sites of ganglions in the hand 4
dorsal wrist
volar wrist
finger felxor sheath
DIP joint
treatment for ganglions 3
leave alone- may spontenously regress
aspirate
excise
who gets OA of hands
FHx
F:M 3:1
presence increases risk of future hip and knee oOA
risk factors for OA hands 5
previous trauma of joint increases the risk of having OA in that joint
obseity
hypermobility of joint
occupation
osteoporosis
-reduced risk of OA
features of hand OA
usually bilateral
episodic joint pain
stiffness
-worse after long periods of inactivity
-only lasts few minutes compared to RA
painless nodes
-heberdens
-bouchards
-due to osteophyte formation
squaring of thumbs
what joints are affected in hand OA
carpomatacarpal joints CMCs
DIPs more than PIPs
-in contract to RA where DIPs are spared
where are heberden nodes
at DIP joints
where are bouchard nodes
PIP joints
management options for OA in hands 2
conservative
-weight loss
-muscle strengthening
analgesia
-PCM
-topical NSAIDs
-oral NSAIds (add PPI )
surgical options for OA of hands 2
arhtrodesis -fusion of bones w interal metal fixation
trapeziectomy-helps OA of thumb
-removes trapezium and insert metal or plastic joint
common signs of rheumatoid hands 6
ulnar deviation of fingers
Z thumb
extensor tendon rupture
boutonniere deformites
swan neck deformites
rheumatoid nodules
describe boutonniere deformites
flexed PIP
hyperextened DIP
describe swan neck defromites
hyperextenion of PIP
flexion of DIP
(think PIPE=swan neck)
what needs to be assessed in amputations and partial amputations 3
level
-finger-tip
-finger-distal to FDS
-hand,forearm, arm
vascularity and time from injury
bone, tendon and nerve injury
complete amputaion vs partial amputation of finger tip injuries
complete amputaion
-generally not suitable for replantation
partial amputation
-presernve and suture back if viable
-excise if non-viable
what is assessed in finger tip injuries 3
bone loss
-viable bone detemines length of finger tip that can be preserved
nail loss
skin loss
aims of treatment for finger tip injuries 3
try preserve as much length as possible
try preserve insertion of FDP
preserve the nail then repair any nail bed injuries
treatment options for finger tip injuries 4
Increasing levels of severity:
dressings
trimming of bone and dressings
terminalisation and primary closer
local advancement or transposition flap
what determines replantation ability of finger amputations
if distal to FDS and proximal to DIP
-idela for replant as PIP is undamaged and likely to be flexible
if proximal to FDS
-just terminalise over replantation as PIP is likely to be very stiff
assessment of hand lacerations 3
vascular assessment
neurological assessment
tendon assessment
vascular assessment in hand lacerations 2
cap refil
pulses
if vascualr compromise but potential for replantation or revasculasraisation then it becomes SURGICAL EMERGENCY
neurological assessment of hand lacerations 2
assess whhcih nerve most likely to be injured from location of laceration
in finger lacerations differentiate between the raidal and ulna digital nerves
neurological assessment of hand lacerations 2
assess whhcih nerve most likely to be injured from location of laceration
in finger lacerations differentiate between the raidal and ulna digital nerveste
tendon assessment of hand lacerations 2
estimate which tendons are likley to be injured from location of lacteration
in finger lacerations differentiate between tenodns of FDS and FDP
treatment of hand lacerations in A&E 4
Local anaesthic and irrigation
DO NOT USE LA UNTIL NEURO ASSESSMENT BEEN MADE
tetanus/ IV ABx
dressing and back slab
low threshold for surgical exploration
-any suspicion of tendon or nerve injury
-refer to ortho/plastics
theatre treatment options for hand laceratsion
tenodn repair
-balace between mobilisation adn immobilisation
-too little mobilisatio-> adhesions and stiffnes
-to aggressive mobilisatio-> rupture of repair
nerve repair
-slow recovery 1mm/day
define fight bite
happens over metacarpo-phalangeal joint
-knucle of fist connects with teeth
Mx of fight bite 4
x-ray for tooth
high risk of penetration of MCPJ
low threshold for surgical irrigation
consider tetanus, debridement
-often ABx if skin has been broken
