hand & wrist Flashcards
1
Q
WRIST FRACTURE where does it occur?
A
occurs in the distal metaphysis of the radius
2
Q
WRIST FRACTURE pathophysiology?
A
- due to FOOSH
- FOOSH causes a forced supination or pronation of the carpal bones which inc the impaction load of the distal radius
3
Q
WRIST FRACTURE colles fracture?
A
- an extra articular fracture of the distal radial metaphysis with dorsal angulation & impaction
- foosh whilst falling forwards
- what deformity does it present with?
4
Q
WRIST FRACTURE smiths fracture?
A
- fractures of the distal radius w volar (palmar) angulation of the distal fragment (opposite of colles)
- foosh whilst falling backwards
- what deformity does it present with?
5
Q
WRIST FRACTURE risk factors?
A
- inc age
- female - why?
- early menopause
- smoking or alcohol excess
- prolonged steroid use
6
Q
WRIST FRACTURE clinical features?
A
- pts typically present following an episode of trauma, complaining of immediate pain +- deformity & sudden swelling around the fracture site.
- neurological involvement? can result in paresthesia or weakness
7
Q
WRIST FRACTURE on examination?
A
- assess for evidence of neurovascular compromise - check nerve function (next card) & limb perfusion (how? x2)
- assess what additional joints?
8
Q
WRIST FRACTURE what nerves do we assess in neurological examination? Using what motor movement and what area for sensation?
https://www.youtube.com/watch?v=2SCvrNd7Xe0
A
- Median nerve: motor – abduction of the thumb; sensory – radial surface of distal 2nd digit
Anterior interosseous nerve: opposition of the thumb and index finger* - Ulnar nerve: motor – adduction of the thumb (‘Froment’s Sign’); sensory – ulnar surface of the distal 5th digit
- Radial nerve: motor – extension of IPJ of thumb; sensory – dorsal surface of 1st webspace
*Ask for an ‘okay’ sign, if the DIPJ of the 2nd digit and IPJ of thumb extend, this signifies AIN nerve involvement
9
Q
WRIST FRACTURE differential diagnoses?
A
- forearm fracture
- carpal bone fracture
- tendonitis
- wrist dislocation
10
Q
WRIST FRACTURES imaging investigations?
A
- x ray. three measurements on an xray help w the diagnosis of a distal radius fracture:
> radial height < ? mm
> radial inclination < ? degrees
> radial (volar) tilt > ? degrees - further CT/MRI used in more complex cases particularly for operative planning
11
Q
WRIST FRACTURE management?
A
- trauma case? resus and stabilise
- closed reduction - technique should ensure enough traction & manipulation under anaesthetic. conscious sedation under ? block?
- now below-elbow backslab cast to restrict wrist & allow healing
- repeat xray after 1 week to check for displacement
- healed? rehab w PT
12
Q
WRIST FRACTURE surgical management?
A
for significantly displaced or unstable fractures as they have a risk of displacing further if not stabalised.
options:
- open reduction & internal fixation (ORIF) w plating
- k wire fixation
pt then in cast to ensure immobility for some weeks
13
Q
WRIST FRACTURE complications?
A
- malunion - shortened radius compared to ulnar leading to ?? x3. treated w ?
- median nerve compression - more common in pts who heal in a significant degree of malunion
- OA - especially w intra articular involvement
14
Q
CTS what is it?
A
carpal tunnel syndrome.compression of the median nerve in the carpal tunnel of the wrist due to inc pressure leading to pain, numbness & paraesthesia in the lateral 3 1/2 digits
15
Q
CTS risk factors?
A
- female
- increasing age
- preganancy
- obesity
- prev injury
- occupation wrepetitive hand or wrist movements eg typing
- associated w what conditions? x3
16
Q
CTS clinical features?
A
- pain, number +- paraesthesia – where?
- why is the palm spared?
- symptoms are worse when?
- how can symptoms be temporarily relieved?
17
Q
CTS on examination?
A
- during early stages of CTS no visible findings
- sensory symtoms reproduced by two tests?
> tinel’s - what is this?
> phalen’s - what is this? - later stages of CTS - weakness of thumb abduction (why?) and/or wasting of the thenar eminence
18
Q
CTS differential diagnosis?
A
- cervical radiculopathy - c6 nerve root involvement = pain in similar distribution but also includes?
- pronator teres syndrome (median nerve compressed by pronator teres) - symptoms extend to where?
- flexor carpi radialis tenosynovitis - distinguished by tenderness at the base of?
19
Q
CTS investigation?
A
- clinical diagnosis
- nerve conduction studies in uncertain cases
20
Q
CTS conservative management?
A
- night wrist splint (how does it work?)
- PT
- corticosteroid injections - injected directly into?
21
Q
CTS surgical management?
A
- only in severely limiting cases where prev treatments have failed
- carpal tunnel release surgery - what is this? done under local and as a day case
- complications? persistant CTS symptoms, infection, scar, nerve damage, trigger thumb BUT post op outcomes are usually good
22
Q
CTS long term comps?
A
permanent neurological impairment that will not improve w surgery
23
Q
all about scaphoid fractures
A
- scaphoid has retrograde blood supply from radial artery so fractures can compromise blood supply leading to avascular necrosis
- high energy trauma leads to fracture. pts present w tenderness in anatomical snuffbox & pain palpating scaphoid tubercle & on telescoping the thumb
- scaphoid series x rays should be taken (ap, lateral, oblique) but fracture may not always be detected. TREAT AS FRACTURED w thumb splint to immobilis wrist and re-xray in 10 days
24
Q
DUPUYTREN’S CONTRACTURE what is it?
A
contraction of the longitudinal palmar fascia starting as painless nodules but then progressing to fibrous cords & flexion contractures developing at the MCP & IPJs (particularly @ ulnar digits - little & ring finger). this can severely limit digital movement & reduce pts QOL
25
DUPUYTREN'S CONTRACTURE pathophysiology
The condition involves a fibroplastic hyperplasia and altered collagen matrix of the palmar fascia. This compositional change leads to a thickening and contraction of the palmar fascia.
The disease progresses in a predictable pattern, although the rate is variable:
1 Initial pitting and thickening of the palmar skin and underlying subcutaneous tissue, with loss of mobility of overlying skin
2 A firm painless nodule begins to form, becoming fixed to the skin and the deeper fascia, gradually increasing inside
3 A cord then develops, resembling a tendon, which begins to contract over months to years
4 Contraction of the cord pulls on the MCP and PIP joints, leading to progressive flexion deformity in the fingers
26
DUPUYTREN'S CONTRACTURE risk factors?
- smoking !!
- alcoholic liver cirrhosis
- diabetes mellitus
- occupational exposure eg?
- technically idiopathic but association w certain genetic & environmental factors
27
DUPUYTREN'S CONTRACTURE clinical features?
- symptoms range from RROM & nodular deformity to complete loss of movement
- ring & little finger (tends to be right hand but 45% bilateral)
28
DUPUYTREN'S CONTRACTURE on examination?
- thickened band or firm nodule adherent to skin may be palpable
- skin blanching may occur on active extension of affected digits
- MCPJ OR PIPJs of affected digits in contracture
- heustons test - what is this?
29
DUPUYTREN'S CONTRACTURE differential diagnoses?
- stenosing tenosynovitis - what is this?
- ulnar nerve palsy - associated w?
- trigger finger - nodule present associated w finger motion
30
DUPUYTREN'S CONTRACTURE investigations?
- diagnosis is clinical
| - pts should ideally have bloods - lfts, hba1c - for risk factor association
31
TRIGGER FINGER what is it?
aka stenosing flexor tenosynovitis is when the finger or thumb can lock in flexion
- can affect 1 or more hand tendons
- occurs spontaneously
32
TRIGGER FINGER pathophysiology?
repetitve movements -> inflammation of tendon & sheath -> flexor tenosynovitis -> trigger fingerf
** can also get nodal formation (where & how?) causes TF as node can't pass under pulley after flexion
33
TRIGGER FINGER risk factors?
- occupation/hobby w prolonged gripping & use of hand
- RA
- DM
- F
- ↑ age
34
TRIGGER FINGER clinical features?
- initially: painless clicking/snapping when trying to extend finger (normally what finger?x2). >1 finger can be involved & may be bilateral
- becomes painful over time (especially at the volar aspect of what joint?)
- digit starts to lock in flexion
35
TRIGGER FINGER OE?
proximal part of the phalanx should be palpated to assess for any clicking, pain w movement & any lumps or masses
36
TRIGGER FINGER differentials?
- dupuytrens - flexion is ? x3
- infection within tendon sheath - preceded w? finger becomes? x3 + passive movement of the digit causes marked pain
- ganglion - involving tendon sheath
- acromegaly - XH GH? swelling of flexor synovium within tendon sheath due to ↑ extracellular volume. limits both?
37
TRIGGER FINGER investigations?
clinical
38
TRIGGER FINGER management?
conservative
- inform & advise eg on activities that causze pain
- splint to hold giner in extension @ night (why?)
-no response/severe? steroid injection
- surgical:
• percutaneous trigger finger release - via needle under local
• surgical decompression (if severe) of tendon tunnel under local or GA
39
TRIGGER FINGER comps?
recurrence is uncommon but adhesions cna form is theres no movement after surgey
40
all about de quervain's tenosynovitis
- inflammation of tendons of nextensor5 pollicis brevis & abductor pollicis longus. F, 30-50 yrs, repetitve movement job/hobby.
- pain@ base of thumb + swelling (due to sheath thickening). grasping or pinching is painful. OE: swelling & palpable thickening. finkelstein's test +ve (???)
- differentials: arthritis of CMC joint, intersection, wartenberg's syndrome
- investigations: clinical +/- plain hand radiograph for exclusion
- management: conservative ie lifestyle (↓repetitive movement) & wrist splint. steroid injection. surgical decompression.
