HAND + WRIST

Question 1

What are some RFs for carpel tunnel?

Answer 1

, 45-60 yo. Risk factors: pregnancy, obesity, diabetes, RA, hypothyroidism, repetitive hand or wrist movement

Question 2

What are the sx of carpel tunnel?

Answer 2

Pain, numbness, paraethesia in the lateral 3.5 digits, weakness

Question 3

What are some of the clinical features of carpel tunnel>

Answer 3

• Wasting of the thenar muscles: flexor pollicus brevis, adductor pollicus, opponens polliicus (late)
• Weakness of thumb abduction (late)
• Palm sparing (innervation by palmar branch of median nerve proximal to carpal tunnel)
• Symptoms worse at night
• Tinels test: percussing over the median nerve
• Fallens test: holding wrist in full flexion for one minute. +ve if pt experiences tingling in sensory distribution of median nerve.

Question 4

How is carpel tunnel managed?

Answer 4

• Management: wrist splint; corticosteroid injections/ NSAIDS (to reduce swelling);
• Surgical only if other treatment fails : carpal tunnel release surgery. Cutting through flexor retinaculum, reducing pressure on the median neve

Question 5

How does dupeytrens contracture arise?

Answer 5

• contraction of the longitudinal palmar fascia.
• Typically starting as painless nodules, fibrous cords and flexion contractures develop at the MCP and ITP joints, which can severely limiting digital movement

Question 6

What are some of the RFs of dupeytrens contracture?

Answer 6

• Smoking*
• alcoholic liver cirrhosis
• diabetes mellitus
• certain occupational exposures (e.g. use of vibration tools or heavy manual work)
• Phenytoin tx
• PMHx of trauma

Question 7

How does dupeytrens present?

Answer 7

• Reduced range of motion
• Nodular deformity
• Loss of movement
• Thickened band
• Skin blanching
• Nodules at interphalangeal and MCP joints

Question 8

How is dupeytrens mxd?

Answer 8

• Conservative: hand therapy, injectable collagenase clostridium hystolicum (early)
• Surgical:
  
  • Indicated if table top test is +ve
  • Excision of disease fascia, fasciotomy – if there are ongoing symtpoms, or flexion >30 degrees:
    
    • Regional fasciectomy - entire cord is removed (most common)
  • Segmental fasciectomy, - short segments of the cord are removed
  • Dermofasciectomy overlying skin are removed, to be followed by a skin graft
• High rate of recurrence

Question 9

What is de quervains tenosynovitis?

Who is it most likely to affect?

Answer 9

• Inflammation of tendons in the first extensor compartment of the wrist
• Extensor pollicus brevis
• Abductor pollicus longus
• Who? Aged 30-50. female. pregnant

Question 10

What are the clinical features of De Quervains tenosynovitis?

Answer 10

• Pain near base of thumb
• Associated swelling
• Difficulty grasping and pinching
• Swelling and palpable thickening over the tendon group of fibrous sheath
• +ve if pt reports aggravated pain over the styloid process
• +ve Finkelsteins test - applying** **longitudinal traction and ulnar deviation to the affected thumb.** **Pain specifically at the radial styloid process and along the length of the extensor pollicis brevis and abductor pollicis longus tendons

Question 11

How is tenosynovitis mxd?

Answer 11

• Conservative: avoid repetitive actions. Splint. Steroid injections
• Surgical decompression: transverse or longitudinal incision made and the tendon sheath split in the central aspect in a longitudinal direction, thus allowing the tunnel roof to form again as it heals but wider and with more space for the tendons to move

Question 12

What is trigger finger and how does it develop?

Answer 12

• Condition where finger/ thumb locks in flexion and cannot extend back
• Can affect one or more tendon in the hand
• Usually after flexor tenosynovitis, repetitive movements cause inflammation of the tendon and the sheath
• Superfical and deep flexor tendons with tenosynotivis develop nodules at the tendon distal to the pully
• When nodules flex the nodule moves proximal to pully, but when they attempt to extend this node fails to pass back under > digit locked in fixed flexed position

Question 13

What are RF for trigger finger?

Answer 13

repetitive motion, prolonged grip and use of the hand, RA, DM., female, age

Question 14

How does trigger finger present?

Answer 14

• Painless clicking and snapping when trying to extend their finger
• Pain over volar aspect of their MCP joint
• Digit begins to lock in flexion

Question 15

How is trigger finger managed?

Answer 15

• Treatment: conservative, steroids, surgical:
• Surgical: percutaneous trigger finger release, if severe: surgical decompression of tendon trial

Question 16

What are ganglionic cysts?

Answer 16

• Ganglion cysts are non-cancerous lumps that most commonly develop along the tendons or joints of your wrists or hands - May also occur in the ankles and feet
• Digital mucous cysts are benign ganglion cysts of the digits, typically located at the distal interphalangeal joints
• Both cysts are the same things, they are just called a ganglion cyst in the wrist and a mucous cyst in the fingers
• Cyst become filled with synovial fluid

Question 17

What are some RFs for ganglionc cysts?

Answer 17

: Female, age, OA, previous joint or tendon injury

Question 18

How do ganglionic cysts present/

Answer 18

• Smooth spherical painless lump adjacent to the joint affected
• On examination, the lump will be soft and will transilluminate
• May mechanically restrict the full range of motion in the affected joint
• If the cyst exerts any pressure upon an adjacent nerves, they may present with localised paresthesia, pain, or motor weakness

Question 19

How are ganglionic cysts diagnosed?

Answer 19

Clinical but can use USS

Question 20

How are ganglionic cysts mxd?

Answer 20

• Generally conservative as self resolving
• Aspiration +/- steroid injection*, although this is associated with infection and high rate of recurrence.
• If severe: Cyst excision, removing the cyst capsule along with a portion of the associated tendon sheath

Question 21

How is blood supplied to the scaphoid?

Answer 21

• The dorsal branch of the radial artery, which supplies 80% of the blood, enters in the distal pole and travels in a retrograde fashion towards the proximal pole.
• Consequently, fractures can compromise the blood supply, leading to avascular necrosis (AVN) and subsequent degenerative wrist disease.
• The more proximal the scaphoid fracture, the higher the risk of AVN.

Question 22

What are some of the features of a scaphoid fracture?

Answer 22

• Fracture following trauma (high energy)
• Sudden onset wrist pain
• Tenderness of anatomical snuff box
• Pain on palpation of scaphoid tubercle

Question 24

How is a scaphoid fracture Ixd +Mxd?

Answer 24

• initial plain radiographs should be taken: AP, lateral and oblique - important to remember that they are not always detected and so if there is any clinical suspicion:
• Wrist immobilised in a thumb splint and repeat plain radiographs in 10-14 days
• If X ray is still -ve but clinical findings suggest scaphoid fracture -> MRI
• Definitive mx:
  
  • Undisplaced fracture: strict immobilisation in a plaster with a thumb spica splint
  • Undisplaced fractures of the proximal pole: high risk of AVN and surgical treatment is potentially indicated if dominant hand + pt is of working age
  • Displaced : surgical mx: percutaneous variable-pitched screw

Question 25

What are the three types of distal radius fractures and how do they present?

Answer 25

1. Colles - extra articular fracture - most common
   
   • Dinner form deformity
   • Dorsally angulated displacement of the distal radial segment
   • FOOSH. Falling on a hyperextended wrist
2. Smiths - extra articular
   
   • Volar angulated and volar displaced
   • From falling backwards / forced pronation injury/ planting outstretched hand behind body
   • Falling on a hyperflexed wrist
3. Barton - intra articular + associated dislocation of the radio-carpal joint. Can be
   
   1. Dorsal
   2. Volar - more common

Question 26

What are the main RFs for distal radius fractures?

Answer 26

Related to osteoporosis

age, Female gender, Early menopause, Smoking, alcohol or Prolonged steroid use

Question 27

What shoul you assess for with a distal radius fracture?

Answer 27

• The neurological examination for a suspected distal radius fracture should include these nerves being assessed:
  
  • 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

Question 28

How are distal radius fractures managed?

Answer 28

All

• Closed reduction, ensuring sufficient traction and manipulation under anaesthetic
• Once stable: place in an below elbow backslab then radiographs repeated after 1 week to check for displacement

Significantly displaced or unstable fractures: surgical intervention e.g. ORIF