Hand + wrist Flashcards
Pain, burning, tingling along median nerve, frequently dropping things
Night pain + numbness
Radiation into forearm, elbow, shoulder, neck and chest
Feels need to “shake” or “rub” hands
carpal tunnel syndrome
Entrapment of medial nerve at wrist – MC compression
carpal tunnel syndrome
PE:
Thenar atrophy (thumb opposition weakness)
Median nerve compression test
+ Phalen’s test
+ Tinel’s sign
Two point discrimination >5mm
Test:
EMG/NCV
XR
carpal tunnel syndrome
How do you treat carpal tunnel syndrome?
Splinting
Steroid injection
Ergonomic modifications
Surgery
Pregnancy = resolves after birth + only can use splint
Nodular or cord-like thickening near distal palmar crease
Ring + pinky most commonly involved
Extension limited, flexion normal
May resemble callus
Non tender
dupuytren’s contracture
RF for dupuytren’s contracture
“Viking” - northern European descent
Genetic
Men >50 years
ETOH, smoking, diabetes, repetitive trauma
thickening/fibrosis of palmar fascia
Dupuytren’s contracture
How do you treat dupuytren’s contracture?
Splints to slow progression
Can try steroid injection or collagenase
Surgery if severe and interferes w/ function
Pain + swelling over radial styloid w/ movement or making a fist
de quervain’s tenosynovitis
Irritation + swelling of tendons on thumb side of wrist (abductor pollicis + extensor pollicis) → inflammation causes constriction → “triggering” or “sticking”
de quervain’s tenosynovitis
+ Finkelstein’s test
Tender to palpitation
Crepitation
XR: to rule out bone pathology, calcium deposit in tendon
Draw blood uric acid to rule out gout
de quervain’s tenosynovitis
How do you treat de quervain’s tenosynovitis?
Immobilize
2 week course of NSAIDS
Injection
Surgery
Dorsal or volar
Painful or painless
Can change in size w/ activity
lump
ganglion of wrist
Cystic structure from synovial sheath or joint cavity, one wave valve
wrist ganglion
A wrist ganglion does/does not transilluminate
does
how do you treat a wrist ganglion?
Reassurance
Immobilization
Aspiration (recurrence)
Surgical excision
2 types of arthritis in your hand
rheumatoid
osteoarthritis
MCP joints + wrists, ulnar drift of fingers, hyperextension of PIP, flexion of DIP (swan neck deformity)
rheumatoid arthritis
DIP + PIP, thumb carpometacarpal
osteoarthritis
rheumatoid vs osteoarthritis
Rheumatoid = systemic affecting synovial tissue
Osteoarthritis = loss of articular cartilage
Bony nodules at DIP = Heberden’s
Bony nodules at PIP = Bouchard’s
Tests:
→ AP/lat/oblique XR
→ blood test: RH factor, CRP, ESR
arthritis
osteoarthritis can be present in the — while rheumatoid arthritis is more present in the phalanges only
thumb
How do you treat rheumatoid arthritis?
systemic treatment (enbrel, remicade), NSAIDs, splinting, injections, therapy, no cure
How do you treat osteoarthritis?
NSAIDS, splinting, surgery
Swelling, discoloration, pain, instability around thumb
ulnar collateral ligament tear
“gamekeeper/skier’s” thumb → forced radial deviation (exact incident occurs)
ulnar collateral ligament tear
XR: AP + lat + oblique views to rule out fracture
Stress views of MP joints w/ comparison
> 30 degree angulation = complete tear
ulnar collateral ligament tear
How do you treat an ulnar collateral ligament tear?
Incomplete = splint
Complete = surgery
Pain + swelling around thumb
bennett’s fracture
Oblique fracture of base of thumb metacarpal
Small fragment remains attached to carpal - metacarpal fragment dislocates
bennett’s fracture
You treat bennett’s fracture with
surgery
Pain over snuffbox, with gripping
Men 20-40
MC fractured carpal bone
Concern for avascular necrosis
scaphoid fracture
> –mm displacement means a high nonunion rate
1mm
How do you treat a scaphoid fracture?
Negative XR = thumb spica cast 1-2 weeks, then re-XR
Positive XR = thumb spica cast x 6 weeks
w/ evidence of healing, continue until healed
If widening/resorption, refer for surgery
Pain, stiffness, swelling on back of hand, Osteonecrosis of lunate, often from lunate fracture
kienbock disease
You will see waht on a kienbock disease imaging?
increased density of lunate
How do you treat keinbock disease?
Immobilize + NSAIDs
Catching of finger, nodule palpable in palm at distal palmar crease
Diabetes, rheumatoid
Kids = thumb
trigger finger
Inflammation of flexor tendon/pulley of thumb, ring, long fingers
trigger finger
How do you treat a trigger finger?
splinting/casting
Injection
surgery
Unable to extend DIP joint
Tender, swollen
mallet finger
MC extensor tendon injury → rupture of extensor tendon at base of distal phalanx
mallet finger
XR: avulsion off dorsal side of distal phalanx
mallet finger
How do you treat mallet finger?
Splint to keep DIP joint in extension for 6-8 weeks
Full time
Tear of central portion of extensor ligament at PIP joint
Flexes from unopposed pull of tendon + DIP joint extends
boutinerre deformity
How do you treat boutinerre deformity?
Splint PIP joint in extension
6 weeks for young
3 weeks for elderly
Pain, swelling, ecchymosis around pinky
→ check for shortening, knuckle depression, rotation
boxer’s fracture
Fracture of 5th metacarpal neck
Hitting someone or a wall
boxer’s fracture
document —- in a boxer’s fracture
angulation
How do you treat a boxer’s fracture
Cast (ulnar gutter)
Surgery if displaced >40 degrees
Pain, swelling, deformity “dinner fork”
Colle’s
MC distal radius fracture - “dinner fork”, fall onto extended wrist
Distal radius fragment tilted upward or dorsal
colle’s
With colle’s and smith’s fractures around the wrist, ALWAYS check –
neurovascular exam
How do you treat a colle or smith fracture?
reduction, cast, surgery
Reverse colle’s – distal fragment tilted downward or volarly
Fall onto flexed wrist
smith’s
animal bites are 90% –
dogs
only 5% cats but more associated with –
infection (pasturella)
How do you treat animal bites?
Irrigation + debridement
Prophylaxis required in high risk bites + patients
All cats
Hand bites by animals or human
amox/clav
Tetanus, rabies prophylaxis
Admit all infected + bites + deep bites
