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2 MSK Clinical Conditions > Hand and Wrist (Session 9) > Flashcards

Hand and Wrist (Session 9) Flashcards

1
Q

What percentage of carpal bone fractures do scaphoid fractures account for?

A

70-80%

(10% of all hand fractures)

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2
Q

What is the most common mechanism for a scaphoid fracture?

A

FOOSH (young adults)

=Hyperextension and impaction of scaphoid against rim of radius

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3
Q

Where do patients usually complain of pain if they have a scaphoid fracture?

A

Anatomical snuffbox

  • Pain=exacerbated by moving wrist*
  • Swelling around radial and posterior aspects of wrist*
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4
Q

Where and how commonly do fractures occur in the scaphoid (%)?

A
  1. Waist: 70-80%
  2. Proximal pole: 20%
  3. Distal pole: 10%
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5
Q

Why are follow-up x-rays sometimes required for a scaphoid fracture? (10-14days after)

A
  • May not show up initially
  • Fracture line may be more visible after some bone reabsorption

(In the meantime- patient should be treated as if they have a fracture if it is suspected)

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6
Q

If a suspected scaphoid fracture still doesn’t show up on an x-ray after 10-14 days and the patient is still symptomatic what should be done?

A

CT/MRI

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7
Q

Describe the blood supply to the scaphoid.

A
  • Mainly retrograde (from distal to proximal pole)
  • Blood supply to proximal pole=tenuous
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8
Q

What type of scaphoid fracture can result in avascular necrosis?

A

Waist of scaphoid

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9
Q

What complications can arise from a fracture in the waist of the scaphoid?

A
  1. Non-union (8-10%)
  2. Malunion
  3. Avascualr necrosis
  4. Carpal instability
  5. Secondary osteoarthritis (non-union, malunion, avascular necrosis)
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10
Q

What is a Colles’ fracture?

A
  • Extra-articular
  • Distal radial metaphysis
  • Dorsal angulation and impaction
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11
Q

What other fracture is associated with a Colles’ fracture in 50% of cases?

A

Ulnar styloid fracture

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12
Q

In which patients are Colles’ fractures common?

(colles’ fracture= most common type of wrist fracture)

A
  • Patients w./ Osteoporosis
    • Post menopausal women
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13
Q

What is the usual mechanism of injury for a Colles’ fracture?

A

FOOSH

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14
Q

How will a patient with a Colles’ fracture present?

A

Wrist=

  • Painful
  • Deformed
  • Swollen
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15
Q

How are most Colles’ fractures treated?

A

Reduction

Immobilisation in cast

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16
Q

What complications can arise following a Colles’ fracture?

A
  • Malunion (dinner fork deformity)
  • Median nerve palsy
  • Post traumatic carpal tunnel syndrome
  • Secondary osteoarthritis
  • Tear of extensor pollicis longus tendon
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17
Q

What is a Smith fracture?

A
  • Distal radius
  • Palmar (volar) angulation- of distal fragment
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18
Q

What % of smith fractures are extra-articular?

A

85%

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19
Q

What % of fractures of the radius and ulna to smith fractures account for?

A

<3%

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20
Q

WIn which patients are Smith fractures common?

A
  • Young men
  • Elderly women
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21
Q

What are the 2 typical mecahnisms for a Smith fracture?

A
  1. Fall onto flexed wrist
  2. Direct blow to back of wrist
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22
Q

What is the ‘garden spade’ deformity?

A
  • Malunion of Smith fracture
  • Residual volar displacement of distal radius
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23
Q

What complication can follow the ‘garden spade deformity’?

A

Deformity narrows-distorts carpal tunnel

=Carpal tunnel syndrome

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24
Q

What is Rheumatoid arthritis? (include the mechanism of its pathology)

A
  • Autoimmune disease
  • Autoantibodies= rheumatoid factor
  • Attack synovial membrane
  • Inflamed synovial cells- proliferate
  • Form pannus - penetrate through cartilage and adjacent bone
  • Causes erosion and deformaties
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25
Q

Name 3 joints which are commonly affected by rheumatoid arthritis.

A
  1. Metacarpophalangeal joints (MCPJ) (Hands and feet)
  2. Proximal interphalangeal joints (PIPJ) (Hands and feet)
  3. Cervical spine
26
Q

Rheumatoid arthritis is often described as ‘symmetrical polyarthritis’. What does this mean?

A
  1. Affects multiple joints
  2. Symmetrical distribution
27
Q

If a patient has rheumatoid arthritis, how might they present? (7)

A
  1. Pain and swelling of joint
  2. Erythema (redness) overlying joints
  3. Stiffness- worst in morning/inactvity
  4. Carpal tunnel syndrome (synovial swelling)
  5. Fatigue/flu-like symptoms (systemic nature of disease)
  6. Rheumatoid nodules - in fingers/elbows (late feature)
  7. Deformities
28
Q

What are the X-ray features of rheumatoid arthritis? (LESS)

A
  • Loss of joint space
  • Erosions
  • Soft tissue Swelling
  • Soft bones (osteopenia)
29
Q

Name 2 deformities that can be seen in patients with advanced rheumatoid arthritis?

A
  1. Swan neck deformity
  2. Boutonniere deformity
30
Q

Describe the ‘swan neck deformity’.

A
  1. PIPJ hyperextends
  2. MCPJ flexed
  3. DIPJ flexed
31
Q

Explain the ‘swan neck’ deformity

A
  • PIPJ- laxed as adjacent synovitis
  • Imbalance between muscles acting on PIPJ
  • DIP- elongation/rupture at insertion of extensor digitorum
32
Q

Describe the Boutinniere deformity.

A
  • MCPJ= hyper extended
  • DIPJ= hyper extended
  • PIPJ= flexed
33
Q

Explain the Boutinniere deformity

A
  • Inflammation in PIPJ
  • Lengthening/rupture of extensor digitorum on dorsal surface of finger
  • Lateral band slips- acts on palmar surface- act as flexor rather than extensor
34
Q

What is psoriasis?

A
  • Skin condition
  • Causes:
    • red, flaky patches of skin- covered with silvery scales
35
Q

Where does psoriasis characteristically occur?

A
  • Elbows
  • Knees
  • Scalp
  • Lower back
  • Can occur anywhere
36
Q

What % of the population has psoriasis?

A

1-2%

37
Q

Does psoriatic arthritis usually develop in a symmetrical of assymetrical manner?

A

Assymetrical

38
Q

How do patients with psoriatic arthritis usually present?

A
  • Fusiform (sausage shaped) swelling of digits (dactylitis)
  • Joints stiffen

Can develop into Arthritis mutilans (widespread joint destruction

39
Q

Rheumatoid arthritis most commonly affects MCPJs and PIPJs. Which joint does psoriatic arthritis most commonly affect?

A

DIPJs

40
Q

What other symptoms do 80% of patients which are affected by psoriatic arthritis have?

A
  • Nail lesions:
    • Pitting
    • Onycholyis (separating nail from nail bed)
41
Q

Name 2 other conditions where Onycholyis (separating nail from nail bed) is seen.

A
  • Hyperthyroidism
  • Fungal nail infection
42
Q

Which joint in the hand is most commonly affected by osteoarthritis?

A

1st Carpo Metacarpal joint

(between trapezium and first metacarpal)

43
Q

In what population is osteoarthritis in the first carpometacarpal joint more common?

A

Women (1/3 of women over 40 yrs will have x-ray changes)

44
Q

How will a patient with osteoarthritis in the first carpometacarpal joint present?

A
  • Pain at base of thumb
  • Pain exacerbated by movement, relieved by rest
  • Stiffness increased following periods of rest
  • Swelling may be evident at base of thumb
  • Squaring of hand (Later)
    • First metacarpal subluxes- ulnar direction
    • Loss of normal contour
45
Q

During which decades of life are patients likely to acquire osteoarthritis in their fingers?

A

5th/6th

46
Q

What are Heberden’s nodes?

A
  • Classic sign of osteoarthritis
    • Typically develop-middle age
    • Tend to run in families
    • More common in women
  • Affect DIPJ
  • Chronic swelling of affected joint
  • Sudden onset of:
    • Pain
    • Swelling
    • Loss of manual dexterity
  • Cystic swelling- contains gelatinous hyaluronic acid-osteophyte left when inital pain and inflammation subsides
47
Q

What are Bouchard’s nodes?

A
  • Classic sign of osteoarthritis
    • Typically develop-middle age
    • Tend to run in families
    • More common in women
  • Affect PIPJs
  • Chronic swelling of affected joint
  • Sudden onset of:
    • Pain
    • Swelling
    • Loss of manual dexterity
  • Cystic swelling- contains gelatinous hyaluronic acid-osteophyte left when inital pain and inflammation subsides
48
Q

What is carpal tunnel syndrome?

A
  • Compression of median nerve as is passes through carpal tunnel
  • Most common site of nerve entrapment
49
Q

Name some risk factors for carpal tunnel syndrome. (5)

A
  1. Obesity
  2. Repetitive wrist work
  3. Pregnancy
  4. Rheumatoid arthritis
  5. Hypothyroidism
50
Q

Name some complications which may follow nerve compression in carpal tunnel syndrome. (4)

A
  1. Ischaemia
  2. Focal demyelination
  3. Decrease in axonal calibre
  4. Axonal loss
51
Q

How will a patient with carpal tunnel syndrome present?

A
  • Paraesthesia in distribution of median nerve
  • Symptoms=worse at night (wrist drifts into flexion- narrows carpal tunnel further)
  • Daily activities can aggravate parasthesia eg driving, combing hair, holding phone
  • Manual dexterity= diminished and difficulty with daily actvities eg buttoning clothes
  • Pain in: forearm, elbow, shoulder, neck (up to 1/3 patients)
52
Q

Why is sensation to the palm spared in carpal tunnel syndrome?

A

Palmar cutaneous branch of median nerve branches proximal to carpal tunnel and passes superficial to it

53
Q

What may happen to the thenar muscles as a result of carpal tunnel syndrome?

  • Flexor pollicis brevis (superficial head)
  • Abductor pollicis brevis
  • Opponens pollicis
A
  • Muscle weakness
  • Atrophy

Motor branch of median nerve exits distal to carpal tunnel (supplies thenar muscles)

54
Q

If a patient has long standing carpal tunnel syndrome, will they still be able to flex and adduct their thumb?

A

Yes:

  • Flexor pollicis longus innervated by anterior interosseous branch of median nerve
  • Flexor pollicis brevis (deep head) innervated by ulnar nerve
  • Adductor pollicis innervated by ulnar nerve
55
Q

What is another name for Ulnar nerve compression in Guyon’s canal?

A
  1. Ulnar tunnel syndrome
  2. Guyon’s canal syndrome
  3. Handlebar palsy
56
Q

How will a patient with ‘Guyon’s canal syndrome present’?

A
  • Parasthesia -ring and little fingers
  • Weakness in intrinsic muscles of hand supplied by ulnar nerve
    • Adductor pollicis
    • Palmar and dorsal interossei
    • Lumbricals to ring and little fingers
    • Deep head of flexor pollicis brevis
57
Q

What is Dupuytren’s contracture? (Common condition)

A
  • Localised thickening+contracture of palmar aponeurosis
  • Causes flexion and deformity
  1. Thickening/nodule in palm (painless/painful)
  2. Myofibroblasts in nodule contract
  3. Tight bands (cords) form
  4. Overlying skin tightly adherent to palmar aponeurosis-now involved
  5. Fingers stuck in flexed position (fixed flexion)
58
Q

Which digits are commonly affected by Dupuytren’s contracture?

A
  1. Ring finger
  2. Little finger
  3. Thumb (may be involved)
59
Q

What population does Dupuytren’s commonly occur in?

A

40-60 years

70% cases have family history- autosomal dominant

More common in males + northern european origin

60
Q

Name 4 examples of conditions that increase a persons risk of developing Dupuytren’s contracture:

A
  1. Type 1 diabetes
  2. Smoking
  3. Hypercholesterolaemia
  4. Heart disease
  5. HIV
  6. Hypo/hyperthyroidism
  7. Trauma to hand/fingers

2 MSK Clinical Conditions (10 decks)

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