Hand & Wrist Flashcards
Carpal tunnel syndrome presentation
Compression of the median nerve at the wrist. It is the most common peripheral nerve entrapment.
Diagnosing Carpal tunnel syndrome
Tinels, Phalens, Reverse Phalens, +/- thenar wasting and electrodiagnositic studies
Tx of Carpal tunnel syndrome
Activity modification, splints, NSAIDS, B12, cortisone injections.
Surgical: open vs endoscopic carpal tunnel release (open- cut the extensor retinaculum.
Risk Factors for Carpal Tunnel Syndrom
Pregnant, DM, hypothyoid, RA, repetitive use
DeQuervain tendonitis
Inflammation of the 1st dorsal compartment. Abductor Policis Longus and Extensor Policis Brevis.
Cause of DeQuervains tendonitis
from repetitive use, insidious onset
Presentation of DeQuervains tendonitis
Pain with thumb extension, abduction or flexion, thumb with ulnar deviation.
Diagnosis of DeQuervains tendonitis
Redness, swelling, crepitus, RSN injections
Tx of DeQuervains tendonitis
Non-surgical: Ice, thumb sicca splint, rest, injection
Surgical: surgical release of 1st dorsal compartment
Finkelstein test
Fist and go down
Trigger finger presentation
irritated tendon- swelling, can form nodule causing finger to catch or lock in flexion or extension.
Cause of Trigger Finger
Excessive Use
Tx of Trigger finger
Non-surgical: Resting, splinting, NSAIDS, injections;
Surgical: Release of Pulley (A1 pulley most common site)
Ganglion cyst presentation
Most common soft tissue tumors of the hand (benign). Cysts are filled with mucin.
Cause of ganglion cysts
obscure
Tx of Ganglion cyst
Reassurance, Aspiration (high recurrence, not recommended for volvar), surgical excision
Locations of Ganglion Cysts
Dorsal (most common)- from SLJ, volvar, radial, retinacular (flexor tendon), mucous cysts (DIPJ)
Occult Ganglion- not visible- SLJ, usually more symptomatic.
Gamekeeper’s thumb labs/tests
Get an X-ray, may see Steners Lesion.
Infectious flexor tenosynovitis presentation
Infection of flexor tendon sheath usually from a puncture. Usually caused by S. aureus.
Infectious flexor tenosynovitis labs/tests
Kanavel Signs
Tx of Infectious flexor tenosynovitis
Requires I&D
Kanavel signs
4 signs of flexor tenosynovitis:
- tenderness along the whole tendon sheath (late sign).
- finger held in flexion.
- fusiform swelling (sausage digit).
- pain with passive extension (earliest finding).
Smith Fractures
Fracture of the distal radius from a PALMAR flexion injury. (Inward).
Colles Fracture
Fracture of the distal radius with DORSAL displacement from a FOOSH.
Boxers Fracture
Fracture of the 5th MC neck as a result of axial load, usually from punching wall, head or mouth. Check for lacerations/cuts on hand for a foreign object (may require removal and I&D)
Risk factors for osteomyelitis
Infection of bone by bacteria or fungus, resulting in bony changes and destruction. Develops by spread of infection from contiguous structures or hematogenous spread.
Etiologies for osteomyelitis
Most common cause is S. Aureus
Clinical presentation of osteomyelitis
Pain at site, warmth, swelling, erythema
Appropriate diagnostic studies for osteomyelitis
Radiographs early in course are normal, later will show bone demineralization, periosteal elevation, late lytic lesions.
Bone biopsy confirms diagnosis/ S. aureus is most common. Blood cultures can help too. Necessary for abx guidance.
Treatment for osteomyelitis
Abx
Finger Infections:
Felon, paranychia, flexor tenosynovitis and herpetic whitlow
Paranychia
infection of the paronchial fold of the nail. Can be bacterial (Staph, MRSA) or fungal (C. albicans)
Cause of Paranychia
Bacterial- puncture, nail biting, hang nail, or artificial nails
Fungal- constantly wet hands, dishwashers, bartenders
Symptoms of Paranychia
Bacterial- pain, tenderness, swelling, abscess (pus), warmth
Fungal- swelling, erythema, deformed nail
Treatment of Paranychia
Bacterial- Bactrim, clindamycin, Keflex, soaks, I&D
Fungal- keep dry, oral or topical antifungals (-azoles)
Dupuyten contracture
Disease of palmar fascia due to palmar fibromatosis causing nodule, cords in fingers and can lead to contractures.
Risk factors for Dupuyten contracture
FHx, M>F, EtOH, Seizure meds, DM, European/Scandinavian, repetitive microtrauma
Symptoms of Dupuyten contracture
Can’t lay flat on table (table top test), +/- pain
Types of Dupuyten contractures
Ledderhose- plantar side of foot
Garrods pads- knuckle pads on fingers
Peyronies disease- fibromas of penis can cause curvature
Treatment for Dupuyten contracture
open excision of ds., needle aponeurotomy, xiaflex injections (collagenase clostridium histolyticum- enzyme that dismantles collagen)
Felon
infection in the tip of the finger (pulp) can form abscess. It is extremely painful and red
Cause of Felon
Usually from a finger puncture; S. Aureus
Caveat of Felon
can spread to bone resulting in osteomyelitis and ito flexor sheath
Treatment of Felon
I&D
Gatekeepers Thumb
hyperextension to MPJ with radial deviation, tearing of the UCL with or with out bone fragment.
Patient Presentation with Gatekeepers Thumb
Pain, swelling, eccyhmosis and weakness with pinch and rotation.
Physical Exam and Treatment for Gatekeepers Thumb
Stress thumb at MPJ level into medial deviation. If enpoint present, can treat with sicca thumb cast. If no endpoint it present, treat with surgery.
Steners Lesion
If bone involved, may see it on X-ray. Bone/tendon is displaced from phalynx. End of UCL is flipped over the adductor aponeurosis and cannot reattach with out surgery.
Special Tests for Gatekeepers Thumb
Stress test for UCL of the thumb
Patient Presentation with a Boxers Fracture
Pain, swelling and tender to palpation
Treatment for a Boxers Fracture
Short arm ulnar gutter cast in most cases. If flexes >40 degrees consider reduction. Usually results in loss of normal cascade of MC with fist, not a functional problem.
Treatment of a Collies Fracture
Non-displaced: sugartong splint/cast (X-ray weekly for 3 wks to make sure it does not displace);
Displaced- ORIF.
ORIF
Open Reduction Internal Fixation
Treatment of a Smiths Fracture
Non-displaced: sugartong splint/cast (X-ray weekly for 3 wks to make sure it does not displace);
Displaced- ORIF.
Animal Bites with the highest risk of infection:
The most common animal bite’s occur from dogs and cats, the risk of infection is much higher from a cat bite compared w/ a dog bite.
Causative organisms for Rabies in Animal Bites:
The most common causative organism for infection is Pasteurella multocida (gram negative rod), esp in cat bites. Staph aureus, alpha-hemolytic streptococci, Bacteroides and Fusobacterium can occur from dog bites.
Human Bites vs Animal Bites
Human bite wounds contain greater concentrations of bacteria compared to animal bites.
Causative organisms for infection in Human Bites
S. aureus and alpha-hemolytic streptococci are MC causative organisms but Eikenella corrodens is also a/w human bite wounds.
Rabies Prophylaxis
Wound cleansing markedly reduces the likelihood of rabies. You should receive a tetanus shot if you have not been immunized in ten years. Should also get a rabies shot!
Mechanism of Injury for a Scaphoid Fracture
FOOSH, minimal swelling most feel it is sprained leading to a delay in diagnosis
Symptoms of a Scaphoid Fracture
Tender to palpation in snuff box.
Treatment of a Scaphoid Fracture
Must treat as if a fracture even with negative findings due to possible decreased blodd supply leading to avascular necrosis. If non-displaced can treat in a thumb spica (6-12 weeks).
For more proximal fracture of displaced- ORIF
Imaging for a Scaphoid Fracture
X- ray in 1st 3 weeks can be negative. May get CT to confirm Diagnosis.
Tendon Function
Full ROM of each tendon against resistance and compare with other side. Pain along course of tendon during resistance testing suggests a partial laceration even if strength appears adequate.
Flexor digitorum profundus: flexing DIP agaisnt resistance while MCP and PIP are held in extension
Flexor digitorum superficialis: flexing PIP joint against resistance while other fingers held in extension
Testing Median Nerve
Actively flex distal phalanx of thumb against resistance
* Opposition by touching tip of thumb to tip of little finger, oppose resistance
Thumb abduction by placing hand palm up and raising thumb to perpendicular while palpating belly of abductor pollicis muscle to ensure it is contrasting
Testing Radial Nerve
Extend fingers and wrist, With thumb in hitchhiking position, test resistance to further extension
Testing Ulnar Nerve
Actively spread fingers apart against resistance and then push them together against resistence.
Hypothenar muscles: extend fingers and move little finger away from others
Thumb adduction: thumb tightly against side of index finger, put paper b/t thumb and index finger and pull away
