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Pocket Primary Care > Hand Disorders > Flashcards

Hand Disorders Flashcards

1
Q

Hand Disorders

A 
Osteoarthritis
Dupuytren Contracture
Trigger Finger
De Quervain tendinopathy
Ganglion cyst
Carpal tunnel syndrome
Cubital tunnel syndrome
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2
Q

Osteoarthritis

Description

A

Hand pain + >/- 3 of: (1) enlargement of >/-2 of 10 joints: 2nd and 3rd DIP/PIP, or any MCP joints from both hands: (2) Firm enlargement of >/-2 DIP joints: (3) -3 swollen MCP joints ; (4) Deformity of >/-1 of 10 joints

Heberden nodes (bumps created by bone spus); PIP 2nd and more variable (bouchard nodes)

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3
Q

Osteoarthritis

clinical presentation

A

Pain worsened w/activity (opening jar, writing), relieved by rest; gelling/stiffness w/inactivity; morning stiffness <30min

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4
Q

Dupuytren contracture

Description

A

genetic fibroproliferative disease (autosomal dominant, incomplete penetrance); collagen within plantar fascia proliferates, thickens, and contracts

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5
Q

Dupuytren contracture

Clinical presentation

A

Painless, palmar skin nodules or cords, which sometimes cause flexion contracture (inability to straighten finger)

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6
Q

Trigger finger (stenosing tenosynovitis)

Description

A

Thickening of the flexor tendon and A1 pulley of the flexor sheath

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7
Q

Trigger finger (stenosing tenosynovitis)

Clinical presentation

A

Sometimes painful snapping (triggering) at PIP joint w/active motion; reluctance to form fist; tender A1 pulley nodule and triggering open from tight fist.

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8
Q

De Quervain tendinopathy

Description

A

thickening and swelling of the tendons of the 1st extensor compartment

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9
Q

De Quervain tendinopathy

clinical presentation

A

Tenderness, pain, and welling at radial aspect of wrist; + finkelstein test (pain w/radial deviation w/thumb in fist)

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10
Q

Ganglion cyst

Description

A

Mucin-filled synovial cyst

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11
Q

Ganglion cyst

Clinical presentation

A

Painless mass, changes in size, characteristic locations; dorsal and volar-radial wrist; dorsal DIP (a/w OA); over A1 pulley (retinacular ganglion cyst)

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12
Q

Carpal tunnel syndrome

Description

A

Genetic compression of median nerve -> sensory and motor neuropathy

Idiopathic median nerve neuropathy in carpal tunnel

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13
Q

Carpal tunnel syndrome

Clinical Presentation

A

Transient numbness in median nerve distribution w/wrist flexion (sleeping, driving) -> eventual constant numbness, thenar atrophy, and weakness

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14
Q

Cubital tunnel syndrome

Description

A

Compression of ulnar nerve at elbow -> neuropathy

Idiopathic ulnar neuropathy in cubital tunnel

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15
Q

Cubital tunnel syndrome

Clinical presentation

A

Initially transient then constant numbness fo the small and ulnar half of ring finger; weakness and atrophy of 1st dorsal interosseous muscle

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16
Q

History

A

Characteristic of given condition (stated earlier); hx of injuries; systemic disease

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17
Q

Exam

A

Examine skin, muscle mass, joints, nails, and overall posture of the digits and wrist, then compare to the contralateral side; grip strength; joint palpation. ROM; test finger and thumb rom by asking pt to actively extend all digits and then forming a composite fist; general alignment of fingernails and overlap of fingertips in fist

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18
Q

Imaging

A

Radiographs after trauma; imaging rarely useful for common dx above

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19
Q

Carpal Tunnel Syndrome

Anatomy

A

The carpal tunnel, made up of the carpal bones and the transverse carpal ligament, keeps the flexor tendons and the median nerve in position when the wrist is flexed; median nerve divides within the carpal tunnel into (1) recurrent motor branch to the thenar eminence (-> thumb weakness) and (2) digital sensory cutaneous branches to thumb, index, middle, and radial half of ring finger (-> hand tingling/numbness)

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20
Q

Carpal Tunnel Syndrome

Epidemiology

A

Estimated 1-5% of entire population; very common disease, increase risk w/age; many pts don’t seek medical attention

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21
Q

Carpal Tunnel Syndrome

Risk Factors

A

Genetics explain 50% of the risk; there are no proven epigenetic factors to date; the evidence that is related to environmental factors is low in quality and inconsistent

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22
Q

Carpal Tunnel Syndrome

DDx

A

cubital tunnel syndrome, neuropathy, cervical radiculopathy

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23
Q

Carpal Tunnel Syndrome

History

A

Intermittent numbness and tingling of the thumb, index, middle, ring ringer (pt may describe the entire hand); classic: awakens pt from sleep or present on waking; not typically a painful condition except that the numbness can be very intense and experienced as pain; pts may report aching in the forearm and arm

24
Q

Carpal Tunnel Syndrome

Exam

A

Sensory: affects threshold sensibility initially (light touch measured) then discriminatory sensibility later (measure w/2pt discrimination)

Motor: In severe disease only; weakness of thumb palmar abduction against resistance; atrophy of thenar muscles

Provocative maneuvers: + if paresthesias (not pain) occur in median nerve distribution, results from greater than 1 test increase se/sp

25
Q

Carpal Tunnel Syndrome

provocative tests

A

Phalen: wrist flexed for 30 seconds se68% sp73%

Tinel: Tap on median nerve proximal to carpal tunnel to paresthesias se50% sp77%

Durkan: Press both thumbs over transverse carpal ligament for 30s se64% sp 83%

26
Q

Carpal Tunnel Syndrome

dx

A

Clinical dx is suspected w/report of classic sc

27
Q

Carpal Tunnel Syndrome

Workup

A

Indications for electrodiagnostic testing debated: used to (1) r/o CTS in reports of paresthesias where it is a possible but les likely dx, (2) provide objective date to manage postoperative expectations in pts w/severe disease; imaging generally not useful in dx

28
Q

Carpal Tunnel Syndrome

Nerve conduction studies

A

Document location and severity of median neuropathy; standard tests include median sensory NCS across the wrist w/distal latency compared to ulnar and radial nerve, and median motor NCS from abductor pollicis brevis

29
Q

Carpal Tunnel Syndrome

electromyography

A

Excludes other peripheral neuropathies

30
Q

Carpal Tunnel Syndrome

Nonsurgical modalities

A

Splinting: brace holds wrist neutral to prevent waking s/numbness

Steroid injection: single injection into carpal tunnel

Modalities s/insufficient evidence: carpal bone mobilization; never gliding; yoga; ergonomic keyboard, oral steroids, U/S

Modalities w/o significant benefit: Diuretics, NSAIDs, Bit b6, magnet Rx, laser acupuncture, exercise

31
Q

Carpal Tunnel Syndrome

Surgery

A

Indicated if failure of nonoperative Rx or median nerve denervation demonstrated on clinical or electrodiagnostic testing

32
Q

Carpal Tunnel Syndrome

Provocative factors

A

Wrist flexion/extension; nocturnal worsening since wrist often flexed during sleep

33
Q

Carpal Tunnel Syndrome

palliative factors

A

shaking or wringing hands, placing hand dependent at side of bed

34
Q

Carpal Tunnel Syndrome

Hand sx diagram

A

Pts mark specific location of sc on self-administered diagram depicting dorsal and palmar aspect of hands/arm

35
Q

Carpal Tunnel Syndrome

Carpal tunnel release

A

Decompression of the carpal tunnel through open or endoscopic complete division of the transverse carpal ligament

Postop care: no indications for wrist immobilization or rehab

Complications: Nerve injury is rare but problematic

Prognosis: Severe disease w/constant numbness and atrophy is permanent; the sx from mod disease usually disappear, but the NCS/EMG does not normalized.

36
Q

Cubital Tunnel Syndrome

Anatomy

A

Ulnar nerve formed by C7/8/T1, passes near medial epicondyle of humerus (at elbow) and between pisiform/hamate bone in wrist

37
Q

Cubital Tunnel Syndrome

History

A

Ulnar neuropathy at elbow -> paresthesias in 4th and 5th fingers, worsened by elbow flexion

38
Q

Cubital Tunnel Syndrome

Exam

A

Tinel test at elbow (percuss elbow -> sx); Neck motion to r/o C8/T1 radiculopathy

39
Q

Cubital Tunnel Syndrome

Workup

A

NCS or EMG to confirm dx and localize lesion

40
Q

Cubital Tunnel Syndrome

Treatment

A

Non-op: brace or pillow to limit elbow flexion at night

Surgery: Generally indicated to avoid; constant numbness, weakness, atrophy

41
Q

Dupuytren Disease

Epidemiology

A

Males>Females, age >40y

Risk factors: genetics (autosomal dominant, variable penetrance): pts w/ ancestry from British Isles and Scandinavia

42
Q

Dupuytren Disease

History

A

Begins as a nodule or cord -> can progress to finger contracture

43
Q

Dupuytren Disease

Exam

A

Nodules in the palmar fascia and/or digits w/occasional pitting of skin; variable PIP and MCP joint contractures

Table top test: + if pt unable to place palm of affected hand flat on a table (usually if MCP contracture is >30degrees)

44
Q

Dupuytren Disease

DDx

A

Soft tissue tumors, stenosing tenosynovitis (note triggering)

45
Q

Dupuytren Disease

Treatment

A

Non-op: Observation of isolated nodules; percutaneous needle fasciotomy, or injectable collagenase for substantial contractures

Surgeries: Excision of diseased palmar fascia (fasciectomy)

46
Q

Trigger Finger (stenosing tenosynovitis)

Epidemiology

A

idiopathic; may be assoc w/DM; Ring»Thumb>long>index>small finger

47
Q

Trigger Finger (stenosing tenosynovitis)

Exam

A

Pain at palmar base of involved digit w/nodule, “catching” and/or locking of digit in flexion as pt tries to extend fingers from fist

48
Q

Trigger Finger (stenosing tenosynovitis)

Ddx

A

Sagittal band insufficiency

49
Q

Trigger Finger (stenosing tenosynovitis)

Treatment

A

Nonop: palliative: NSAIDs, splinting: disease modifying: corticosteroid injection into the tendon sheath (works approx. 50% of the time, can take 2 mos to show efficacy)

Surgery: Release of digital A1 pulley

50
Q

De Quervain Tendinopathy

Epidemiology

A

Seen in both sexes in adults of all ages: often seen 6 weeks postpartum

51
Q

De Quervain Tendinopathy

Exam

A

Focal tenderness over the 1st dorsal compartment of the wrist

Finkelstein test: + pain w/ulnar deviation of the wrist w/the thumb in fist

52
Q

De Quervain Tendinopathy

Ddx

A

Trapeziometacarpal arthritis of the thumb (no crepitus and stiffness)

53
Q

De Quervain Tendinopathy

Treatment

A

Nonop: NSAIDs, thumb spica wrist spling, corticosteroid injection in the 1st dorsal compartment

Surgery: Release of 1st extensor compartment

54
Q

Ganglion Cyst

Epidemiology

A

Idiopathic; most common hand/wrist tumor

55
Q

Ganglion Cyst

Exam

A

Well-circumscribed, smooth, mass usually located adjacent to joints and tendons (ie dorsal or volar wrist); can be intratendinous or intraosseous; transilluminates

56
Q

Ganglion Cyst

Ddx

A

Lipomas, neuromas, hamartomas, sarcoma, vascular aneurysms

57
Q

Ganglion Cyst

Treatment

A

Nonop: Observation, as many spontaneously resolve; avoid aspiration
(clear, gelatinous fluid) on volar surface as often abuts radial rtery

Surgery: Excision (5-10% recurrence rate)

Pocket Primary Care (18 decks)

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