Hand/Wrist Disorders

Question 1

Animal Bites

Answer 1

• Most commonly occur on the fingers of the dominant hand of children. 10% dog bites, 30-50% cat bites, 5% other.
• Risk of infection is 5-10% for dog bites, 30-50% for cat bites (deeper puncture wounds)
• Organisms:
  
  • Pasteurella. multocida, S. aureus, Strep sp.
• S/sxs:
  
  • S/sxs of infection: pain, swelling & redness around puncture wound
  • → nerve damage: loss of sensation & motion
• PE:
  
  • Need to complete a neurovascular exam before using an anesthetic (bites often associated with nerve/tendon injuries)
• Dx:
  
  • Xray to r/o fracture
  • -Labs: CBC, ESR, CRP (to follow the injury)
  • -Gram Stain
• Tx:
  
  • Debridement, wound irrigation with saline solution, & outpt abx (Ceftriaxone/Augmentin)
  • -Loose closure
  • -Suturing is controversial (only if wound is clean after debridement)
  • -Tetanus prophylaxis
  • -Referral & close f/u

Question 2

Arthritis of the Hand

Answer 2

• Most commonly caused by osteoarthritis & secondary degenerative joint diseases → loss of articular cartilage, bony changes at joint margins, & subchondral cyst formation
• Joints:
  
  • OA: DIP, PIP, hum carpometacarpal joint
  • -RA: wrist, metacarpophalangeal joints
• S/sxs:
  
  • Stiffness and loss of motion in the fingers
• PE:
  
  • OA:
    
    • -Heberden nodes (DIP)
    • -Bouchard nodes (PIP)
    • -Grind test
  • RA:
    
    • -Fusiform swelling of multiple joint
    • -Boutonniere deformity
    • -Swan neck deformity
• Dx:
  
  • -Xray: PA, oblique, lateral
  • -May need ESR/CRP, RF, ANA, ACC if no dx established
• Tx:
  
  • *Tx each type of arthritis (see rheum)-OA: NSAIDs, splinting, arthroplasty/fusion
  • -RA: NSAIDs, cortisone injections, splinting, referral to OT

Question 3

Arthritis of CMC/Thumb

Answer 3

• Definition: idiopathic degenerative arthritis of the thumb carpometacarpal joint
• Risks: women 40-70yo
• S/sxs:
  
  • -pain at the base of the thumb: worse with grip & pinch activities, may radiate to wrist & forearm
  • -decreased pinch strength
  • -”catching” or “clicking” with certain movements
• PE:
  
  • Tenderness over the palmar and radial aspects of the joint in the region around the base of the thumb
  • -Pain & crepitus with manipulation of the CMC joint
  • -Grind test: grip metacarpal bone of thumb & move in circle → sharp pain
• Dx:
  
  • Carpal tunnel can mimic arthritis of CMC but will have positive Phalen’s & decreased sensation in the median nerve distribution
  • Xray → joint space narrowing, subchondral sclerosis, subluxation or dislocation
• Tx:
  
  • Conservative: soft column brace, NSAIDs
  • -Corticosteroid injections

Question 4

Arthritis of the Wrist

Answer 4

• Most commonly caused by previous trauma or rheumatoid arthritis
• S/sxs:
  
  • Wrist swelling, tenderness, & limited ROM
  • -Pain with daily activities
  • -decreased grip strength
  • -Radial deviation of the wrist
• PE:
  
  • Swelling, increased warmth, limited ROM, & pain on palpation
• Dx:
  
  • Radiography:
    
    • -OA: subchondral sclerosis, joint space narrowing, spur formation
    • -RA: osteopenia (thinning of bone structure) with erosions)
• Tx:
  
  • *Tx each type of arthritis (see rheum)
  • -OA: NSAIDs, splinting, arthroplasty/fusion
  • -RA: NSAIDs, cortisone injunctions, splinting, referral to OT

Question 5

Boutonniere Deformity

Answer 5

• Definition:
  
  • finger flexed at the PIP joint & hyperextended at the DIP joint
• Mechanism:
  
  • central portion of the extensor tendon ruptures at its insertion onto the middle phalanx → PIP joint flexes from the unopposed pull of the flexor tendon
• S/sxs:
  
  • *history of trauma
  • -Finger held partially flexed at the PIP joint & extended at the DIP joint
  • -Painful tender
• Dx:
  
  • Xray to r/o fracture
• Tx:
  
  • Splint PIP in extension x 4-6 weeks
  • -Hand surgeon f/u

Question 6

Carpal Tunnel Syndrome

Answer 6

• Definition: median nerve entrapment & compression at the carpal tunnel
• Risks:
  
  • women, DM, pregnancy, hypothyroidism, RA, occupations with repetitive extension & flexion of the wrist (typing)
• S/sxs:
  
  • -Paresthesias or pain of the palmar aspect of the 1st 3 digits radial aspect of the 4th digit
  • -Nighttimewaking d/t pain
• PE:
  
  • Tinel test: percussion (Tapping) of median nerve reproduces sxs
  • Phalen test: flexion (Phlat against each other) of both wrists for 30-60 seconds reproduces sxs
  • -Atrophy (if advanced)
• Dx:
  
  • -Nerve conduction velocity
• Tx:
  
  • Conservative: night splint, NSAIDs, avoid repetitive wrist movements
  • -Corticosteroid injections
  • -Refractory: carpal tunnel surgery

Question 7

De Quervain’s Tenosynovitis

Answer 7

• Definition:
  
  • stenosing inflammation of the tendons (entrapment tendonitis) of the 1st dorsal compartment
• Mechanism:
  
  • excessive thumb movement with repetitive action
• Risks:
  
  • golfers, clerical workers, women postpartum (lifting newborns), DM
• S/sxs:
  
  • pain along the radial aspect of the wrist & base of the thumb radiating to the forearm especially with thumb extension
  • -Swelling & thickness over the tendon sheath
• PE:
  
  • Finkelstein test: first dorsal compartment pain with ulnar deviation while the thumb is flexed in the palm with thumb extension
• Dx:
  
  • clinical dx, xray will be normal
• Tx:
  
  • Conservative: thumb spica splint, ice, NSAIDs, & PT
  • -Corticosteroid injections
  • -surgical release

Question 8

Dupuytren’s Contracture

Answer 8

• Definition:
  
  • progressive fibrosis of the palmar fascia leading to contractures as a result of nodules or longitudinal bands in the palm
  • aka “Viking’s disease”
• Risks:
  
  • men > 40yo, N. Europeans, EtOH, cirrhosis, DM, smoking
• S/sxs:
  
  • visible or palpable nodules over the distal palmar crease or proximal phalanx along the course of the flexor tendons
  • -thickened skin or bands in the palmar fascia
  • -Fixed flexion deformity at the MCP joint with limited extension of the MCP or PIP joint
• Trauma can accelerate the issue → including needle insertion & surgery.
• Dx:
  
  • clinical dx
• Tx:
  
  • Extension splint, PT
  • -Corticosteroid injections
  • -Surgical correction: PNA (aponeurotomy), PPF (partial palmar fasciectomy)

Question 9

Emergent Finger Infections

Answer 9

• Typically occur in the pulp (palmar tip) of the finger (felon) & in the soft tissues directly surround the fingernail (paronychia)
• Types:
  
  • Felon: puncture wound
  • -Paronychia: ingrown nail
  • -Herpetic Whitlow: HSV
• S/sxs:
  
  • -Felon: severe pain & swelling in the pad of the fingertip
  • -Paronychia: swelling of the tissues around the fingernail (usually on one side)
  • -Herpetic whitlow: vesicles with clear fluid
• Dx:
  
  • clinical dx
• Tx:
  
  • Medical Emergency
  • -Felon: surgical drainage & oral abx
  • -Paronychia: warm moist soaks & oral abx if severe, may need to remove nail plate (if so, should place a cover at the proximal edge of the nail bed so that
  • -Herpetic whitlow: observation

Question 10

Flexor Tendon Injuries

Answer 10

• Definition:
  
  • laceration or rupture of the flexor tendons of the hand → loss of flexion at the DIP or PIP joints
• Rupture Risks:
  
  • OA, RA (direct synovial invasion of the tendon), trauma (caught on jersey), chronic wear over bony osteophytes
• Anatomy:
  
  • -Flexor digitorum profundus (FDP): inserts onto the distal phalanx
  • -Flexor digitorum sublimis (FDS): inserts onto the middle phalanx
• S/sxs:
  
  • FDP Rupture:
    
    • -Patient can flex MCP & PIP, but NOT the DIP
  • FDS Rupture:
    
    • -Patient can flex MCP, PIP, & DIP (unless joint is isolated→ see PE)
• PE:
  
  • Test for active flexion, then passive flexion
  • -Test flexion of both the DIP & PIP joints
  • -FDS test: hold fingers straight then have the pt flex each finger individually at the PIP joint → PIP flexion will not occur when the other joints are held extended
  • -Two point discrimination
• Dx:
  
  • Xray → may show a small, avulsed fragment from the distal phalanx in the FDP rupture
• Tx:
  
  • Dorsal blocking splint
  • -refer for consultation & surgical repair

Question 11

Flexor Tenosynovitis (Suppurative)

Answer 11

• Definition:
  
  • infection of the felxor tendon synovial sheath of the finger
• Etiology:
  
  • puncture wound, spread from superficial infection
• S/sxs:
  
  • * hx of recent puncture wound to flexor surface
  • Progressive swelling to the entire digit & significant pain (24-48 hours after injury)
• PE:
  
  • Kanavel’s Sign: FLEX
  • -Finger held in flexion
  • -Length of tendon sheath is tender
  • -Enlarged finger (fusiform swelling)
  • -Xtension of the finger causes pain
• Dx:
  
  • XR → soft tissue swelling, possible foreign body
  • biopsy
• Tx:
  
  • IV Abx
  • -Incision & drainage with irrigation of tendon sheath & debridement (to be done by a hand surgeon)

Question 12

Trigger Finger

Answer 12

• Definition:
  
  • swelling of the flexor tendon sheath at A-1 pulley (tenosynovitis = swelling of the sheath)
• Mechanism:
  
  • thickening of the flexor tendon or first annular pulley from chronic inflammation or irritation
• Risks:
  
  • middle-aged women, RA, DM, hypothyroidism, carpal tunnel syndrome
• S/sxs:
  
  • Pain & catching/snapping when they flex the finger
  • Describes the finger as “going out of joint”
  • Wake up with finger locked in the palm (may unlock during the day)
  • Swelling & stiffness in fingers
  • *Pt may identify PIP as source of pain, but pathology is at MCP joint
• PE:
  
  • Tenderness in the palm at the level of MCP joint
  • Palpable nodule at the MCP joint
  • Pain with passive flexion of PIP joint flexion
• Dx:
  
  • Clinical dx
• Tx:
  
  • Conservative: night splint POPJ, NSAIDs
  • -Corticosteroid injections
  • -Surgical trigger release (outpt, pretty common)

Question 13

Scaphoid (Navicular) Fracture

Answer 13

• Mechanism:
  
  • fall on outstretched hand (FOOSH)
• Most commonly fractured carpal bone. Often missed → delayed treatment. Healing time: 12 weeks
• Poor blood supply (comes from distal to proximal) so it has poor healing outcomes
• S/sxs:
  
  • Pain along the radial surface of the wrist with anatomical snuffbox tenderness
• Dx:
  
  • Xray:
  • -Need scaphoid view
  • -Fracture may not be evident for 2 weeks, but if snuffbox tenderness is present then tx as fracture (d/t complications)
• Tx:
  
  • Nondisplaced fracture or snuffbox tenderness: thumb spica splint or cast with repeat xray q 4 weeks
  • -Displaced > 1mm: ORIF

Question 14

Colles Fracture

Answer 14

Fx of the Distal Radius

• Definition: distal radius fracture with dorsal angulation
• Mechanism: FOOSH with wrist extension
• S/sxs:
  
  • Wrist pain worse with passive motion
• PE:
  
  • swelling, deformity, discoloration around the wrist
  • dinner fork deformity
• Dx:
  
  • Xray:
  • -dorsally displaced or angulated extraarticular fracture of the distal radius on lateral view
• Tx:
  
  • -Stable: closed reduction & sugar tong splint or cast
  • -Unstable: ORIF

Question 15

Smith Fracture

Answer 15

• Definition:
  
  • distal radius fractural with ventral angulation
• Mechanism:
  
  • FOOSH with wrist flexion
• S/sxs:
  
  • wrist pain worse with passive motion
• PE:
  
  • swelling, deformity, & discoloration around the wrist
  • garden spade deformity
• Dx:
  
  • XR ventrally displaced or angulated extra articular fracture of the distal radius on lateral view
• Tx:
  
  • -Stable: closed reduction & sugar tong splint or cast
  • -Unstable: ORIF

Question 16

Bennett/Rolando Fracture

Answer 16

• Definition:
  
  • an oblique fracture of the thumb metacarpal that enters the CMC joint
• Mechanism:
  
  • axial force applied to thumb in flexion
• S/sxs:
  
  • pain, swelling, & ecchymosis at the CMC joint
  • limited ROM
• Bennet vs Rolando:
  
  • Bennet: non-comminuted partial intra-articular fracture
  • Rolando: comminuted complete intra-articular fracture
• Dx:
  
  • -Xray:
  • -AP, lateral, oblique view
  • -Bennet: small fragment of 1st metacarpal base
  • -Rolando: Y sign (splitting of 1st metacarpal base into dorsal & volar fragments)
• Tx:
  
  • -Immediate: thumb spica splint for temporary stabilization
  • -Bennet: closed reduction & percutaneous pinning
  • -Rolando: ORIF

Question 17

Boxer’s Fracture

Answer 17

• Definition:
  
  • fracture through the fifth metacarpal neck
• Mechanism:
  
  • direct trauma to closed fist against a hard surface
• S/sxs:
  
  • Pain along the dorsum of the 5th metacarpal of the hand with swelling, ecchymosis
  • Rotational deformity
  • Pt can tolerate up to 30 degree deformity of the metacarpal neck if the phalanges are not affected.
• Dx:
  
  • XR
• Tx:
  
  • -ulnar gutter splint with joints in at least 60 degrees of flexion
  • -Surgery: if fifth remains > 40 degrees angulated
  • -check for bite wounds

Question 18

Hook of Hamate

Answer 18

• Definition:
  
  • involves the palmarmost aspect of the hamate bone of the wrist
• S/sxs:
  
  • *hx of repetitive or direct trauma
  • pain at the base of the ulnar side of the hand
• PE:
  
  • pressure over the hook of hamate will elicit pain & swelling
  • numbness along ulnar nerve distribution
• Dx:
  
  • XR but caution b/c often interpreted as normal
• Tx:
  
  • immobilize wrist in neutral position
  • may need hook of hamate excision

Question 19

Lunate Fracture

Answer 19

• Most serious carpal fracture since the lunate occupes ⅔ of the radial articular surface
• S/sxs:
  
  • acute wrist swelling & pain
• PE:
  
  • *note: lunate dislocation is an orthopedic emergency. Requires reduction/splint followed by ORIF
• Tx:
  
  • immobilization with orthopedic referral
    *

Question 20

Human Bite

Answer 20

• Organism:
  
  • Eikenella corrodens (anaerobes in the mouth), Staph, Strep
• s/sxs:
  
  • *History of injury (may be hard to identify)
  • -Laceration
  • -Warmth, swelling, pain & purulent discharge
  • -Lack of extension or flexion (d/t tendon damage)
• PE:
  
  • Measure & record location of laceration
  • -Assess function of flexor/extensor tendons & sensory nerves
• Dx:
  
  • Xray to r/o fracture or presence of foreign body
  • -WBC, ESR, CRP (to follow injury)
• Tx:
  
  • Debridement, wound irrigation, & outpt abx; do not close wound
  • -Referral
  • -Tetanus prophylaxis
  • *Wounds that involve the joint, tendon, nerve, or bone require further eval

Question 21

Mallet Finger

Answer 21

• Definition:
  
  • inger flexed at the DIP joint & unable to actively extend at the DIP joint
• Mechanism:
  
  • avulsion of the extensor tendon after sudden blow to tip of finger → forced flexion of an extended finger
• S/sxs:
  
  • -unable to actively extend the DIP joint → usually caused by jamming your finger
• Dx:
  
  • Xray = normal or avulsion fracture of the distal phalanx at the tendon insertion site
• Tx:
  
  • Nonoperative: uninterrupted extension splint of DIP x 6-8 weeks with f/u
  • -Surgery: closed reduction & percutaneous pinning