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MSK 2023 > Hand and wrist disorders > Flashcards

Hand and wrist disorders Flashcards

1
Q

Most common carpal to be fractured

A

Scaphoid

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2
Q

Who are scaphoid fractures common in?

A

Adolescents and young adults

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3
Q

How do scaphoid fractures occur?

A

FOOSH

hyperextension and impaction of scaphoid against radius or direct axial loading of scaphoid

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4
Q

Presentation scaphoid fracture

A

Pain in anatomical snuff box
Exacerbated by moving wrist
Swelling around radial wrist

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5
Q

Common location scaphoid fracture

A

Waist of scaphoid

can occur proximal pole and distal pole (scaphoid tubercle

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6
Q

X-ray scaphoid fracture

A

May not show up initially
Need follow up x-ray 10-14 days after (visible after bone resorption)

If still not visible but symptomatic, CT/MRI

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7
Q

Blood supply scaphoid

A

Retrograde blood supply - distal pole supplied before proximal
Avascular necrosis can occur in proximal scaphoid during waist fracture

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8
Q

What do waist fractures have high risk of (due to retrograde blood supply)?

A 
Non union
Malunion
Avascular necrosis 
late:
carpal instability 
Osteoarthritis
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9
Q

when is osteoarthritis common post scaphoid fracture?

A

If non union, malunion or avascular necrosis

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10
Q

What is colles fracture?

A

Extra-articular fracture of distal radial metaphysis
dorsal angulation (of distal segment)
impaction

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11
Q

What can occur alongside colles fracture?

A

Ulnar styloid fracture (50% cases)

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12
Q

Most common type distal radial fracture

A

Colles

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13
Q

Who is most at risk colles fracture?

A

Osteoporosis
–> Post menopausal women

(if younger, high impact)

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14
Q

How does colles fracture occur?

A

FOOSH
Pronated forearm
Dorsiflexed wrist

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15
Q

Patient presentation colles fracture

A

Painful
deformed
swollen wrist

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16
Q

Colles fractures treatment

A

Reduction and immobilisation in cast

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17
Q

Deformity colles fracture

A

Malunion = dinner fork deformity (hand curled up and then down)

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18
Q

Complications colles fracture

A

Malunion (dinner fork)
Median nerve palsy
Post traumatic carpal tunnel syndrome
Tear of extensor pollucis longus tendon (tendon over sharp fragment of bone)

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19
Q

Smith fracture - what is it

A

Fractures of distal radius with volar (palmar) angulation of distal fragments

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20
Q

What can smiths fracture be thought as

A

85% extraarticular - reverse colles fracture

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21
Q

Who is most at risk smiths fractures?

A

Young males

Elderly females

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22
Q

How can smith fracture occur?

A

Fall onto dorsum of hand when wrist flexed

Direct blow to back of wrist

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23
Q

What deformity can malunion of smiths fracture result in?

A

Garden spade - volar displacement

can narrow and distort carpal tunnel and cause carpal tunnel syndrome

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24
Q

Where does rheumatoid arthritis commonly occur in the hand?

A

MCPJ

PIPJ

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25
Q

What is RA?

A

Autoantibodies known as rheumatoid factor attack the synovial membrane
Inflamed synovial cells form pannus
Pannus erodes cartilage and bone

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26
Q

How is rheumatoid arthritis described?

A

Symmetrical polyarthritis - affects multiple joints symmetrically

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27
Q

Problem with symmetrical arthritis

A

Swelling symmetrical

Difficult to diagnose as no reference to ‘normal’ to compare to

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28
Q

Presentation RA

A 
Pain/swelling MCPJ/PIPJ
erythema overlying joints
stiffness (worse morning/inactivity)
carpal tunnel syndrome (from synovial swelling)
fatigue and flu-like symptoms 
RA rheumatoid nodules
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29
Q

Rheumatoid nodules

A

Late presentation
Fingers and elbow

seen less frequently now

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30
Q

RA x ray features

A

Loss of joint space
Marginal bony Erosions (juxta-articular)
Subluxation/deformity
Osteopenia

(soft tissue swelling too)

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31
Q

Deformities associated with RA

A

Swan neck

Boutonniere

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32
Q

Swan neck

A

MCPJ flexed
PIPJ hyperextends
DIPJ flexed

(down, up, down)

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33
Q

What happens to tissues swan neck?

A

Palmar aspect (volar) tissues become lax from adjacent synovitits

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34
Q

What can occur to tendon in swan neck?

A

Rupture of insertion of extensor digitorum (distal phalanx) which can result in mallet deformity

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35
Q

What is Boutonniere?

A

MCPJ extended
PIPJ flexed
DIPJ extended

(up down up, opposite to swan)

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36
Q

What occurs during boutoniere deformity?

A

Rutpture/lengthening of central slip of extensor digitorum
Lateral bands can slip down the side of finger to palmar surface
can start to act as flexors at PIPJ

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37
Q

Psoriatic athropathy

A

Psoriasis results in this (small minority)

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38
Q

What is psoriasis?

A

Skin condition
red, flaky patches of skin
silvery scales

(elbows, knees, scalp and lower back commonly)

39
Q

Psoriasis arthritis signs

A

Asymmetrical oligoarthritis (one joint at a time, then progressing asymmetrical manner. eg left big toe and then right index finger)

40
Q

Where is psoratic arthiritis common?

A

Small joints of hands and feet

41
Q

Presentation of psoriatic arthiritis

A

Fusiform (sausage shaped) swollen digits - aka dactylitis
Distal affected joints
Can progress to widespread destruction - arthritis mutilans
Nail lesions

42
Q

What joints does psoriatic arthiritis affect?

A

DIPJ (unlike RA)

43
Q

Nail lesions psoriatic arthiritis

A

Pitting

Oncholysis (seperation from nail bed)

44
Q

Joint mostly affected by OA in hand

A

1st carpometacarpal joint (trapezium and 1st metacarpal)

45
Q

OA in hand common risk people

A

Women

46
Q

Presentation OA hand

A

Pain at base of thumb - exacerbated by movement, relieved by rest
Stiffness increases after rest (morning)
Swelling at base of thumb - loss of squaring/contour of hand

47
Q

OA in fingers presentation

A

5th/6th decade of life

gradual pain DIPJ

48
Q

Node sign of OA

A

Heberdens nodes
Affect DIPJ
women >, middle aged, genetic?

49
Q

How do herbedens nodes progress symptoms?

A

Chronic swelling of joints
Sudden pain
Loss of dexterity

50
Q

herbedens nodes growth

A

Cystic swelling - gelatinous hyaluronic acid dorsolateral DISTAL IPJ
Inflammation and pain subside - left with osteophyte

51
Q

Other node

A

Same as herbedens process but in PIPJ = Bouchards

52
Q

Carpal tunnel syndrome =

A

Compression of median nerve as it passes through carpal tunnel from forearm to hand

53
Q

Risk factors carpal tunnel syndrome

A 
Obesity
Repetitive wrist work
Pregnancy
RA
Hypothyroidism
54
Q

What can carpal tunnel syndrome lead to?

A

Ischaemia
Focal demyelination
decrease in axonal calibre
axonal loss

55
Q

Presentation carpal tunnel syndrome

A

Parasthesia of median nerve (thumb, index finger, middle finger, radial half ring finger)
Worse at night (wrist flexes)
Daily activities (driving/brushing hair) can worsen

56
Q

What sensation is spared in carpal tunnel syndrome?

A

Palmar sensation - palmar cutaneous branch of median nerve branches before carpal tunnel so passes superficial to it

57
Q

Muscles affected carpal tunnel syndrome

A

Atrophy/weakness of Thenar muscles - motor branch median nerve exits distal to carpal tunnel so affected

58
Q

Thenar muscles

A

Flexor pollucis brevis
Opponens brevis
abductor pollucis brevis

59
Q

What action of thumb will patient be able to do with carpal tunnel syndrome?

A

Still able to flex thumb (even though part of flexor pollucis brevis has lost supply)

Flexor pollucis longus is innervated before carpal tunnel (anterior interosseus branch median nerve)
Deep head of flexor pollucis brevis is also UNAFFECTED (ulnar nerve)

Adduction is spared as adductor pollucis is supplied by ulnar nerve

60
Q

What actions are lost during carpal tunnel syndrome?

A

Manual dexterity (eg buttoning up shirt) is lost

61
Q

Pain carpal tunnel syndrome

A

Proximal forearm, elbow, shoulder and neck

62
Q

Where can ulnar nerve be compressed?

A

Guyons canal

63
Q

Where does ulnar nerve pass in guyons canal where it can be compressed?

A

Radial/lateral to pisiform and over flexor retinaculum

64
Q

Ulnar nerve compression =

A

Ulnar tunnel syndrome
Guyons canal syndrome
Handlebar palsy (wrists on handlebars = compressed)

65
Q

Ulnar nerve compression presentation

A

Parasthesia in ring/little fingers

Weakness of intrinsic hand muscles (adductor pollicis, palmar and dorsi interossei, lumbricles - ring and little finger)

66
Q

What is Dupuytren contracture?

A

Localised thickening and contracture of palmar aponeurosis leading to flexion of adjacent fingers

67
Q

Process Dupuytren contracture

A

Nodule on palm - painful/painless
Myofibroblasts within nodule contract = tight bands called cords in palmar fascia
Overlying skin (tight to fascia) becomes involved
Proximal fascia and skin on fingers involved
Fingers stuck in flexed position

68
Q

Common digits Dupuytren contracture

A

Ring and little finger (first webspace/thumb may be invoved)

69
Q

Common people affected dupuytren

A

Males 40-60 years old
Northern europe
Family history - Autosomal dominant

70
Q

Conditions that increase risk of Dupuytrens contracture

A 
Type 1 diabetes
Adhesive capsulitis (frozen shoulder)#
Epilepsy
Liver disease/excessive alcohol consumption
Smoking
Hypercholestrolaemia 
Heart disease
HIV
Hypo/hyperthroidism 
Trauma
Vibration injury
71
Q

injury to radial nerve in radial groove - upper arm effects

A

If injured in mid shaft fracture of humerus, it travels in radial/spiral groove so could be damaged

Triceps will still be intact as already branched (long and lateral prior to groove, short proximal to fracture)

Aconeus will lose supply

But still able to extend arm

72
Q

injury to radial nerve in radial groove - lower arm effects

A

Wrist and fingers flexed
Extensors of wrist and fingers supplied by radial nerve

(when pronated)

73
Q

Sensory impairment radial nerve damage in radial groove

A

Posterior cutaneous nerve of forearm unaffected (already branched)
Lower lateral cutaneous nerve unaffected (already branched)

Paraesthesia in superficial branch of radial nerve = lateral 3 1/2 dorsum hand (not finger tips)

74
Q

High median nerve injury

A

No muscular branches to arm - all just before medial epicondyle
If supracondylar fracture occurs - all these muscles affected (anterior forearm)
Pronation and flexion weakened (except flexor carpi ulnaris and ulnar half of flexor digitorum profundus)

75
Q

Arm position high median nerve injury

A

Supinated (supinator and biceps brachii)

Adduction (flexor carpi ulnaris pulls)

76
Q

thumb high median nerve injury

A

Flexion thumb = weak (still have deep flexor pollucis brevis)
opposition and abduction of thumb = absent

77
Q

Fingers high median nerve injury

A

Flexor digitorum superficialis = paralysed
flexor digitorum profundus (index and middle finger) paralysed

MCPJs can still flex as interossei (ulnar nerve) can work

78
Q

Fist of median nerve injury

A

Ring and little fingers can flex to palm normally - ulnar nerve supply of FDP and lumbricles
Index and middle fingers = fully extended

79
Q

Position thumb median nerve injury

A 
IPJ's and MCPJ = extended (extensor pollucis longus is unapposed)
Thumb = adduction (unapposed adductor pollucis, abductor pollucis = lost supply)
Lateral rotation (loss of opponens pollucis)
80
Q

Muscles intrinsic hand supplied by median nerve

A 
LOAF
Lateral lumbricals
Opponens pollicis 
Abductor pollucis brevis
Flexor pollucis brevis
81
Q

Clinical sign of fist of median nerve damage known as

A

Hand of Benediction (flexed ring and little finger, other s extended)
ONLY SEEN WHEN TRYING TO MAKE FIST
NOT AT REST

82
Q

Long term median nerve damage =

A

Ape hand deformity

Thenar wasting

83
Q

Injury to median nerve at the wrist cause

A

Penetrating (eg glass) or compression of carpal tunnel

84
Q

Presentation low median nerve injury

A

Innervation of common flexor origin = intact

Palmar cutaneous sensory branch to palm = spared

85
Q

Muscles paralysed in lower median nerve injury

A

LOAF
Lateral lubricles (index and middle finger)
Opponens pollucis
Abductor pollucis brevis
Flexor pollucis brevis (superficial head)

86
Q

Thenar eminence atrophied =

A

Ape hand deformity (thumb adducted and laterally rotated)

87
Q

Ulnar nerve injury at wrist muscles/area spared

A

Flexor carpi ulnaris
Flexor digitorum profundus (ulnar half)
Palmer cutaneous branch (ulna edge of palm, already branched)

88
Q

Ulnar nerve damage muscles injured

A

Hypothenar eminence:
Opponens digiti minimi
Flexor digiti minmi brevis
Abductor digiti minimi

adductor pollicis
dorsal/palmer interossei
Medial Lumbricles - little and ring finger
palmaris brevis

89
Q

Long standing ulnar nerve damage

A

Claw hand - affects little and ring fingers (looks like sign of benediction)
2 fingers extended at MCPJ and flexed at IPJ’s

90
Q

Why do you get claw hand with ulnar nerve damage?

A

Lumbricals 3 and 4 are paralysed (1 and 2 are intact - median nerve)
Lumbricles flex at MCPJ and extend at IPJ’s

= MCPJ unapposed extension from extensor digitorum
= IPJ’s unapposed flexion from long flexor FDP and FDS

(extensor digitorum cannot appose FDP and FDS as energy dissipated at MCPJ)

91
Q

What does wasting of interossei, hypothenar and adductor pollucis result in?

A

Interossei - guttering between metacarpals

1st interossei and adductor pollucis = loss of bulk of first webbed space

Hypothenar = loss of bulk of hypothenar

92
Q

Injury to ulnar nerve at elbow =

A

All muscles/skin innervated by ulnar nerve (discussed in other card)
+ flexor carpi ulnaris, flexor digitorum profundus (ulnar section) and loss of sensation of palmar nerves

93
Q

Explain ulnar paradox

A

Proximal nerve injury gives more pronounced claw sign
(you would think distal = larger effects but NO)

In distal, flexor digitorum profundus (ulnar part) is also paralysed so no flexion occurs at DIPJ of ring and little finger

MSK 2023 (55 decks)

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