HAND AND WRIST DISORDERS

Question 1

Describe scaphoid fractures

Answer 1

-Most common carpal bone frature
-May occur at any age but most common among young adults

Question 2

What is the MOI of scaphoid fractures?

Answer 2

-FOOSH resulting in hypertension and impaction of the scaphoid against the rim of the radius.

Question 3

What is the presentation of scpahoid fractures?

Answer 3

-Pain in the anatomical snuffbox
-Pain exacerbated by moving the wrist
-Passive range of motion is reduced
-Swelling around the radial + posterior aspects of the wrist is common.

Question 4

Which part of the scapohoid do fractures normally affect?

Answer 4

-Waist of the scaphoid
(can also occur in the proximal/distal pole)

Question 5

What is important to note in Xrays for scaphoid fracture?

Answer 5

-Plain Xrays taken immediately after injury may not reveal the fracture
-delayed diagnosis is common
-If intial Xray does not show fracture= Follow up xray 10-14 days after.

Question 6

What are some complciations of scaphoid fractures?

Answer 6

-(scaphoid) Blood supply is mainly retrograde from distal pole to proximal pole.
-Fractures through the waist of the scaphoid can result in avascular necrosis.
+
-non union, malunion, secondary OA, carpal instability

Question 7

What is the management of scaphoid fracture?

Answer 7

-Open reduction and internal fixation
-Casts

Question 8

What is a Colle’s fracture?

Answer 8

-Extraarticular fracture of the distal radial metaphysis with dorsal angulation and impaction

Question 9

What is a risk factor for Colle’s fracture?

Answer 9

-Patients with Osteoporrosis (most frequently post menopausal women)

Question 10

What is the MOI of a Colle’s fracture?

Answer 10

-FOOSH with a pronated forearm and wrist in dorsiflexion

Question 11

How will a patient present with a Colle’s fracture?

Answer 11

-Painful deformed and swollen wrist
-Dorsal angulation and impaction are usually clearly visible on plain Xrays.

Question 12

What is the treatment of Colles fracture?

Answer 12

-Reduction and immobilisation in a cast

Question 13

What are some complication of Colle’s fracture?

Answer 13

-Malunion resulting in ‘dinner fork’ deformity
-Median nerve palsy
-Post traumatic carpal tunnel syndrome
-Secondary OA
-Tear of extensor pollicis longus tendon (attrition of the tendon over a sharp bone fragment)

Question 14

What is a Smith’s fracture?

Answer 14

-Fracture of the distal radius with palmar angulation of the distal fragment.
-Typically occur in young males and elderly females

Question 15

What is MOI for a Smiths’s fracture?

Answer 15

-Fall onto the dorsum of a flexed wrist
-Direct blow to the back of the wrist

Question 16

What are some complications of a Smith’s fracture?

Answer 16

-Malunion resulting in garden spade deformity
-This deformity narrows and distorts the carpal tunnel so can result in carpal tunnel syndrome.

Question 17

what is rheumatoid arthritis?

Answer 17

-Autoimmune disease in which autoantibodies (rheumatoid factor) attack the synovial membrane
-Inflamed cells proliferate to form a pannus which penetrates through the cartilage and adjacent bone.

Question 18

which joints in the hand are most commonly affected by rheumatoid arthritis?

Answer 18

-MCPJ
-PIPJ
-Cervial spine
-Can also involve the large joints

Question 19

what do patients with rheumatoid arthritis of the hand often present with?

Answer 19

-Pain and swelling of the PIPJs and MCPJ of the fingers
-Erythema overlying the joints
-Stiffness (worse after rest)
-Carpal tunnel syndrome
-Fatigue and flu like symptoms
-Rheumatoid nodules (late feature)

Question 20

What are common deformities seen in RA of the hand?

Answer 20

-Swan neck deformity
-Boutonniere deformity

Question 21

What is swan neck deformity

Answer 21

-Tissues on the palmar aspect of PIPJ become lax leading to hyperextension
-DIPJ becomes flexed due to problem with insertion of extensor digitorum into base of distal phalanx.

Question 22

What is boutonnieres deformity?

Answer 22

-MCPJ and DIPJ are hyperextended and the PIPJ is flexed due to slipping of extensor digitorum bands now acting as flexors

Question 23

What is psoriatic arthropathy?

Answer 23

-Psoriasis is a skin condition that causes red flaky patches of skin covered with silvery scales.
-Patient with psoriasis can develop arthritis

Question 24

What is the presentation of psoriatic arthropathy?

Answer 24

-Fusiform swelling of the digits known as dactylitis.
-Affected joint will stiffen
-Can result in widespread joint destruction (arthritis mutilans)
-Patients can have nail lesions: pitting and onycholysis

Question 25

What is the treatment of Psoratic arthrits?

Answer 25

-Corticosteroids
-DMARDs
-Biologics

Question 26

Which joint of the hand is most commonly affected by OA?

Answer 26

-1st carpometacarpal joint (between the trapezium and 1st metacarpal)
-more common in women

Question 27

How does a patient present with OA of 1st CMCJ?

Answer 27

-Pain at the base of their thumb
-Pain exacerated by movement and releived by rest
-Stiffness following periods of rest
-Swelling around base of the thumb

Question 28

What are Heberden’s nodes?

Answer 28

-Classical sign which affect the DIPJ of fingers
-Cystic swelling containing gelatinous hyaluronic acid on dorsolateral aspect of the DIPJ.
-Initial inflammation and pain will subside leaving an osteophyte.
-This process in the PIPJs are called Bouchard’s nodes.

Question 29

What is Carpal tunnel syndrome?

Answer 29

-Compression of the median enrve as it passes through the carpal tunnel into the hand
-most common site of nerve entrapment

Question 30

What are risk factors of Carpal tunnel syndrome?

Answer 30

-Obesity
-Reptitive wrist work
-Pregnancy
-Rheumatoid arthritis
-Hypothyroidism

Question 31

What can result from carpal tunnel syndrome?

Answer 31

-Ischaemia
-Focal demyelination
-Decrease in axonal calibre
-Eventually axonal loss
-Loss of motor function to the thenar muscle leading to atrophy

Question 32

What is the presentation of carpal tunnel syndrome?

Answer 32

-Paraesthesia in the distribution of the median nerve
-Symptoms are often worse at night
-Daily activities can aggravate paraesthesia

Question 33

How do you remeber the cause of carpal tunnel syndrome?

Answer 33

MEDIAN TRAP Pneumonic

Question 34

Describe ulnar nerve compression in Guyon’s canal?

Answer 34

-Ulnar nerve can be compression in Guyon’s canal as it passes radial to the pisiform bone over the palmar surface of the flexor retinaculum.

Question 35

How does a patient present with Guyon’s canal syndrome?

Answer 35

-Paraesthesia in the ring and little fingers progressing to weakness of the intrinsic muscles of the hand supplied by the ulnar nerve.

Question 36

Which intrinsic muscles of the hand will be weakened GCS?

Answer 36

-Adductor pollicis
-Palmar and dorsal interossei
-Lumbricals to the ring and little fingers
-Deep head of flexor pollicis brevis

Question 37

What is Dupuytren’s contracture?

Answer 37

-Localised thickening and contracture of the palmar aponeurosis leading to a flexion deformity of the adjacent fingers.

Question 38

What is the presentation of Dupuytren’s contracture?

Answer 38

-Initially patient notices thickening or nodule in the palm which may be painless.
-Later myofibroblasts within the nodule contract leading to formation of tight bands called ‘cords’ in the palmar fascia.
-Casuses finger to be stuck in a flexed position.

Question 39

In which patients in Dupuytren’s contracture commonly seen?

Answer 39

-Occurs most commonly ages 40-60
-More common in males and people of northern european origin
-Inheritence is autosomal dominant (70% of cases have family history)

Question 40

Which conditions can increase risk of Dupuytren’s contracture?

Answer 40

-Type 1 diabetes
-Smoking
-HIV
-Heart disease
-Trauma to hand or fingers
-Thyroid disease