hand, wrist, and ortho infections Flashcards
boxer’s fx
- fx through base of 5th metacarpal neck
- occurs when closed fist strikes hard surface
- volar angulation up to 40 degrees acceptable
- rotational deformity cannot be accepted
treatment of boxers fx
- volar angulation > 45 degrees then reduce fx
- unlar gutter cast for 3-4 weeks then splint
- surgical repair
bennett fx
- two part intra-articular fx and dislocation of the base of the 1st metacarpal
- d/t forced abduction
- common thumb fx
xray findings for bennett fx
- 2 piece intraarticular fx at base of thumb
- dorsolateral dislocation
- sm fragment of 1st mc continues to articulate with trapezium
- lateral reduction of 1st mc shaft by abductor pollicis longus
rolando fx
- comminuted bennett fx dislocation
bennett fx treatment
- CRPP fixation
- thumb spica for 4-6 weeks
- if reduction not possible then ORIF with cortical screw
scaphoid fx
- most frequently fx carpal bone
- usually in waist of scaphoid
- cannot miss these fx- can cause necrosis
- usually d/t foosh
- time for union takes longer in proximal fx
major blood supply to scaphoid
- retrograde flow from dorsal carpal branch of radial artery
clinical findings for scaphoid fx
- TTP over anatomical snuff box
- TTP over scaphoid tuberosity
- limited wrist flex/ext
- radial and ulnar deviation cause pain on radial side
- forced dorsiflexion= very painful
treatment for scaphoid fx
- nondisplaced- thumb spica cast for 6 weeks then short thumb spica until signs of union
- immobilization 16 weeks- 6 months
- cast changes q10-14 days for 1st 6 weeks
- if displaced ORIF then thumb spica
basal joint arthritis
- more common in post-menopausal women
- insidious onset radial thumb pain worsens with use
- decrease ADLs, strength, dexterity
- pain with thumb opposition
clinical presentation of basal joint arthritis
- dorsoradial prominence of thumb mc base secondary to subluxation
- TTP at trapexiometacarpal joint and scaphtrapezial joint
- crepitus
- grind test -> pain
treatment of basal joint arthritis
- NSAIDs
- splinting
- ice
- intraarticular cortisone inj
- total joint replacement via anchovy technique
carpal tunnel syndrome
- most common compressive neuropathy of UE
- median nerve compressed by transverse ligament
- d/t decreased canal size or increased volume of soft tissue
diagnosis for carpal tunnel
- tinel sign- tap over transverse ligament
- phalen sign- have pt press backs of hands against each other for a few min
treatment for carpal tunnel
- wrist splint- 20 degrees ext
- pt
- ergonomics
- steroid injection
- surgery
dequervain’s syndrome
- stenosing tenosynovitis of 1st dorsal compartment
- abductor pollicis longus and extensor pollicus brevis
- most common in women on dominant hand
clinical presentation of dequervain’s syndrome
- pain
- swelling
- TTP over dorsal radial aspect of wrist
- worse with activity
diagnosis of dequervain’s sydnrome
- finkelstein test- fist made with thumb inside fingers then ulnar deviate
treatment for dequervain’s syndrome
- rest/ activity modification
- thumb spica
- NSAIDs
- PT
- steroid inj
- surgical decompression
gamekeeper’s thumb
- injury to ulnar collateral ligament of them at MCP joint
- instability of MCP joint and decreased grip strength
- aka skier’s thumb
diagnosis of gamekeeper’s thumb
- plain films may not show deviation
- perform stress test
- MRI for surgical planning
treatment of gamekeeper’s thumb
- conservative for partial tear- thumb spica for 4-6 weeks
- surgical repair for full tears
- surgery required for stener lesion
stener lesion
- piece of first metacapral gets avulsed off with a gamekeeper’s thumb
treatment for finger dislocations
- reduce
- volar alumafoam splint
- buddy tape with gauze between fingers
- tylenol, NSAIDs
- ice
- follow up with hand surgeon
mallet finger
- disruption of ext mechanism of finger at DIP joint
- occurs when DIP undergoes sudden flexion
- often when ball strikes tip of finger
- can cause bony avulsion injury or tendinous injury
clinical presentation of mallet finger
- inability to extend DIP
- slight flexion at rest
treatment for mallet finger
- stax splint for 6-8 weeks with DIP in 10 degrees hyperextension to be worn AT ALL TIMES
jersey finger
- avulsion of flexor digitorum profundus from insertion at base of distal phalanx
- results from sudden hyperext of actively flexed finger
- mainly seen in ring finger
clinical presentation of jersey finger
- inability to flex finger at DIP
- TTP over volar aspect of distal finger
- xrays usually normal
- may have bony avulsion fragment at distal phalanx
- MRI- disruption of FDP at volar vase of distal phalanx
treatment for jersey finger
- conservative for partial tear
- surgical intervention for all complete tears
trigger finger
- stenosing flexor tenosynovitis
- d/t repetitive micro-injury from frequent flexion or extension
- causes thickening of flexor tendon/ sheath and A1 pulley
- common in adult women 50-60
clinical presentation of trigger finger
- difficulty straightening or bending affected finger
- transiently locked into flexed position
- with a painful snap can go into extension
- often have to manually extend finger
treatment for trigger finger
- NSAIDs
- splinting
- steroid injection
- surgery to release A1 pulley- very successful and is an OP procedure
Dupuytren’s contractures
- palmar fibromatosis -> firm nodule on volar surface of hand
- results in loss of full ext of hand and fingers
- usually in older males
associated diseases of Dupuytren’s contractures
- DM
- epilepsy
- alcoholism
- keloids
- plantar fibromatosis
clinical presentation of dupuytren’s contractures
- thickening or nodules on palm
- painless at first -> eventually inflamed and painful
- ulnar side of both palms frequently involved
- 4th and 5th digits affected earliest
treatment for dupuytren’s contractures
- cortisone inj into sheath
- collagenase inj
- prophylactic external beam radiation to slow progression
- surgery with open fasciotomy
ganglion cyst
- most common soft tissue tumor of hand
- usually dorsal aspect of wrist
- fluid filled swelling over a joint or tendon
- gelatinous or mucinous fluid
- d/t over use near the affected joint
clinical presentation of ganglion cyst
- swelling
- joint pain +/- tenderness
- smooth, firm, rounded
treatment for ganglion cyst
- splinting
- needle aspiration- apply jelly like appearance
- surgical removal
- may reoccur with needle aspiration and surgery
mucous cysts
- benign cyst usually at DIP on dorsal surface
- associated with OA
- dev later in life
clinical presentation of mucous cysts
- visible swelling on dorsal side of finger
- translucent nodule that may be painful
- groove in finger nail d/t pressure on matrix
treatment for mucous cysts
- steroid injection- triamcinolone
- surgical excision only when really necessary
nail bed injuries/ lacerations
- most nailbed injuries also involve DIP fx
- usually d/t crush injury
- can have simple lac or stellate lac
- simple lacs dont extend into peripheral tissue
treatment for nail bed injuries
- repair, can be complex
- anesthesia- finger block or sedation
- NO epi
- adhesives may be used instead of stitches
- subungual hematomas require trephination
- if nail elevation dont remove nail
- suture distal portion of nail bed
complex stellate nail bed repair
- need to remove nail plate
- any free tissue put back into place
- suture nail bed and plate back
- small absorbable sutures used
- trephination of nail
crush injuries to nail bed
- can cause tuft fx or distal phalanx fx
- repair nail bed and replace nail plate
- if displaced then reduce and suture
missing nail plate repair
- repair nail bed
- reinforce silicone or sterile petroleum gauze
- new nail will eventually grow
compartment syndrome
- muscle fascia prevents expansion of tissue
- surgical emergency in acute setting- limb threatening
- usually assoc with closed injuries of extremities
- can occur in casted extremity
- venous outflow decreases as arterial flow increases
common sites for compartment syndrome to occur
- leg and forearm
- radius
- ulna
- proximal tibia
- especially when casted
what causes acute compartment syndrome
- usually trauma
what causes chronic compartment syndrome
- usually in athletes
what causes nontraumatic compartment syndrome
- animal bite
- IVDU
- prolonged compression of a limb i.e. after a fall when pt cannot get up
- thrombosis vascular disease
five P’s of compartment syndrome
- pain*** out of proportion to injury
- pallor
- pulselessness
- paresthesias
- paralysis
treatment for compartment syndrome
- fasciotomy of each compartment
- return to OR for closure at later date
what are the most common organisms involved in ortho infections?
- staph
- strep
- MRSA
imaging for ortho infections
- xray affected area- FB or periosteal thickening
- early septic arthritis shows joint space widening
- US if suspect abscess
what does periosteal thickening plus boney erosions indcate
- osteomyelitis
treatment for ortho infections
- empiric abx
- I&D
- splint
- elevate hand/ extremity
- moist hot pack
- pain control
- tetanus if needed
hand infections
- can be limb threatening
- often from cat bite, human bite, puncture wounds
- always xray IVDU to look for needle tip
what is the bacteria associated with cat bites?
- pasturella
kanavel’s four cardinal signs of infective flexor tenosynovitis
- swelling of entire finger
- partially flexed position
- tenderness limited to course of flexor tendon sheath
- disproportionate pain on passive ext of finger
tx for hand infections
- IV abx for specific pathogens
- pain mgmt
- surgical wash out
- keflex, cefazolin, clinamycin, unasyn, vanco
herpetic whitlow
- caused by HSV
- intensely painful finger tip
- usually distal phalanx
- toddlers more susceptible d/t thumb sucking
clinical presentation of herpetic whitlow
- painful, edematous finger tip with vesicular lesion
- often on thumb and index finger
- clinical dx
treatment of herpetic whitlow
- generally self limited
- symptomatic
- unroof tense vesicles
- acyclovir either PO or topical
felon
- infection of fingertip pulp
- thumb and index finger most common
- can lead to ischemic necrosis and osteomyelitis
- can be d/t untreated paronychia
clinical presentation of felon
- throbbing pain
- tension
- edema
- erythema
- dx clinically
treatment of felon
- I&D
- abx for staph and MRSA coverage
- cephalexin, bactrim, clinda, dicloxacillin, doxycycline
